GW1-2021-00808_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATERZONEs
FROM TO I DESCRIPTION'S
Well Contractor Name 90 f• 110 ft. 5 gpm
2465-A 170 ft- 175 ft. 5gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 56 ft- 6 1/8 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-too
0 A nO FROM TO DIAMETER THICKNESS MATERIAL
2
2.Well Construction Permit#: 0- 98 tt. & in.
List all applicable Nell permits ri.e.Counly,State,Variance,Injection,etc.)
ft. fit. ,in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 fit 35 fit Bentonite Pumped
❑Monitoring ❑Recovery
Injection WeIL• ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier g• tt.
❑Aquifer Test ❑Stormwater Drainage
fir. fit.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colorhardmii3,soiVroek in",elr
❑Geothermal Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fit 19 fL Brown Dirt
8/6/21 19 ft. 34 ft. Brown Rock
4.Date Well(s)Completed: Well 1D#
34 fit. 200 ft- Slate
Sa.Well Location: ft ft
North Union Development LLC fit. rt
Facility/Owner Name Facility lD#(if applicable)
ft ft Seams:65',90'-110'=5 gpm, 170'=5gpm
3436 Rilla Hamilton Rd., Monroe 28110
ft. fL
Physical Address,City,and Zip 21 REMARKS
Union 08078001 B
County Parcel Identification No.(P[N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C rtification
(ifwell field,one latflong is sufficient) /
N W 7/1 rV 8I20/21''',f
Si lure ofCertitied Well Contractor fl Date ri 'CHiI
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form, 1 hereby certify thatithe well(s)was(were)canstructed in accordance
with I5A N(:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy ofihis retard 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:21 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.
Nor 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: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdi(/erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 32 (fL) Division of Water Resources,Information Processing Unit,
Ifrvarer level is above casing,use"+^ 1617 Mail Service Ceriter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.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) 1 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county heat Ith department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013