GW1-2022-04291_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used far single or multiple wells
1.Well Contractor Information:
14.
Dwight L. Huneycutt , FROMATE TO R ZONES DESCRIPTION
Well Contractor Name 7 169 ft 175 f° 40 gpm
4070-A �,PR Q g 202" ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING
T HILNR f a icablc
FROM TO formul MAT ERIALMEd
Derry's Well Drilling, Inc. t 0 ft 50 ft 16 1/8 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
21-112 FROM TO DIAMETER i THICKNESS MATERIAL
2.Well Construction Permit ti: ft. ft. In.
List all applicable well permits(i.e.Coumy,Stale,Variance,injection,etc..)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) % f`' to
❑industrial/Commercial ❑ FR
Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rt 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa 'cable' .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if aecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock IyM gngn size,Mc
❑Geothermal(Tieating/CoolingRetum) ❑Other(explain under 421Remarks) 0 ft- 6 ft. Brown Dirt
10/16/21 g ft 18 f` Brown Rock
4.Date Well(s)Completed: Well RM ft it
18 185 Slate
Sa.Well Location: ft. ft.
Jason Taylor ft ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft
Seams: 88',95', 115', 169'=40g
822 Lawyers Rd E, Monroe 28110 ft. ft
Physical Address,City,and Zip 21.REMARKS
Union 08162012J
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) ,
W 11/9/21
N
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary Ay signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A MAC 02C.0200 Well Construcllon Standards and that a
7.is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the ihell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under rill 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.
hor multiple injection or non-water supply wells ONLY with the sane consn uchon,you can
submit one form SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this for in within 30 days of completion of well
Nor multiple wells list all depths ifdii ferem(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: (ft.)
21 Division of Water Resources,information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Welts ONLY: in addition to sending the form to the address in
Rota 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) 40 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
Farm GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resoiuces Revised August 2013
i ,