GW1-2022-04293_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES
cu
9 Y FROM TO DESCRIPTION
Well Contractor Name ) i 370 iL 375 tt 1 gpm
4070-A 'j .. ` ' fL ft.
APR g
NC We0 Contractor Certification Number /v 1. - 15.OUTER ER CASING for multi cased wells OR LINRR if a livable
FROM TO DIAMETER TIrCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 65 fL ti 1/8 SDR-21 PVC
Company Name '` 16.INNER CASING OR TUBING(geothermal closed-loo
a FROM K TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20-1 1 37,, ` k. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
k. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRICIewss MATERIAL
❑Agricultural ❑Municipal/Public k k, m
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) k• fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 k. 3 it, Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 35 k• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardn soil/rack type Min sir eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under 421 Remarks 0 ft. 7 ft. Red Clay
4.Date Well(s)Completed: 11/2/21 Well UM 7 k• 28 ft. Brown Dirt
28 ft. 51 ft Brown Rock
5a.Well Location:
Ronnie Laney 51 f 500 ft.
Slate
t.
Facility/Owner Name Facility ID#(if applicable) fL
Pigg-Mattox Rd., Monroe 28112 (Lot 3) Seams:70',75',so', , 135', 173',
ft. ft. 330',370'=Ig1g,425'
Physical Address,City,and Zip 21.REMARKS
Union 04-072-015G
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) //
N W
�44H . C_.. 11144� 11/25/21
Signature ofCYrtified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9lNo 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#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.
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: 500 24a. For All Wells: Submit this ibrm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 65 (ft,) 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 Wells 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: ry constriction 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 Mad 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 health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013