GW1-2021-00814_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
Y FROM TO I DESCRIPTION
Well Contractor Name 195 it. 225 ft' 30 gpm
2465-A IL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi used wells ORLINER if a livable
FROM TO DIAMETER THIC(QVFSS MATERLIL
Derry's Well Drilling, Inc. 0 f' 47 iL 6 1/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed400
19-43 FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
[]Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. It. in.
❑Industrial/Commercial DResidential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 iL 3 ft- Bent.Chips Gravity
NoD-Water Supply Well: 3 ft- 35 f`• Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: fr. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft MATERIAL I I EMPLACEMENT METHOD
❑Aquifer Test ElStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soilirock in shte,etc.
DGeothermal (Heating/Cooling Return ❑Other lain under#21 Remarks 0 ft 8 i` Red Dirt
4.Date Well(s)Completed: 8/31/21 Weil ID# 8 fL 16 i`• Brown Dirt
16 ft 25 IL Brown Rods
5a.Well Location:
25 i` 225 i` Blue Rock
Christopher&Susan Medlin ft. ft.
Facility/Owner Name Facility ID#(if applicable)
2305 Henry Baucom Rd, Monroe 28110 f t ft. Seams:56',9 5107`j115=1201%
195 22 -3d'9
Physical Address,City,and Zip 21,REMARKS
Union 08072004D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) aN �, goife, 9/20/21
Si of Certified Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the ivell owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair tinder#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 ivells ONLY ivith the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100D construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,information Processing Unit,
If ivater level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.Borehole diameter- 6 (in.) 24b.For Infection 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:
(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) 30 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 health department of the county where
constructed.
i
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013