GW1-2021-00807_Well Construction - GW1_20211208

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt F4.WATERZONES
John W. Hune
Y FROM TO DESCRII'T10N
Well Contractor Name 85 tt' 100 11. I 7 gpm
2465-A n
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER trap licable
FROM TO DIAMETER TmCHIVESS MATERIAL
Derry's Well Drilling, Inc. 0 45 n 6 1/8 1tl SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
21-159 FROM TO DIAMETER! THICKNESS MATERIAL
2.Well Construction Permit#: ft, fL in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. h in.
❑Agricultural ❑Municipal/Public
❑Geothermal eatin Coolie Supply) ❑Residential Water Supply ft. R• in.
❑Industria/Commereial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERL►I.. EMPLACF1MNT METHOD&AMOUNT
❑Ir i ation 0 n' 3 n' Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring [:]Recovery
n 35 n Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
IA FROM TO MATERL' EMPLACEMEW METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
n. rL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If uecessn
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREP17ION color,hard, wit/rocktype, etc.
❑Geothewal eatin Coolie Return ❑Other(explain under#21 Remarlts 0 ft' 8 ft.
Red Dirt
7/7/21 8 n 16 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
16 R 26 B Brown Rock
5a.Well Location: 26 fi 225 Slate
Brandon S. Plyler n
Facility/Owner Name Facility ID#(if applicable) B, ft.
Seams:85'=7g,115',.1_45',._�
523 Hopewell Church Rd., Monroe 28110 tt. -- r
Physical Address,City,and Zip 21.REMARKS
Union 08183002C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or dechn tl degrees: 22•Certification:
(if well field,one tat/long is sufficient) / �
N W /LNG `„,' �GtIZQ'c� 8/1/21
Si of Certified Well Contractor Date
6.Is(are)the weB(s): Permanent or ❑Temporary By signing this form,I hereby certify that!the tvell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 249. For Au Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenr(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 41 (ft•) Division of Water Resources,Information Processing Unit,
If nmter level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test' Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form,within 30 days of completion of
136.Disinfection type: Amount: 1/2 lb. re
Granular well construction to the county health department of the county whew
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Re sources Revised August 2013
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