GW1-2022-04303_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:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name — 150 ft. 153 fL 1 gpm
2465-A = . -' 'i,� i '' ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a livable
R'ar 777 FROM TO DIAMETER'. THIC[[i7dTES5 MATERIAL
Derry's Well Drilling, Inc. 0 ft. 56 ft- 61/8 'i^ I SDR-21 I PVC
Company Name 1 16.INNER CASING OR TUBING eothermal dosed-loop)
�•• •�,--P^;\ ^.UI•!-I FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20-618 mow:'",; •1:1'1'iGrl 'it���J •, ft. ft. in.
,r-c�
List all applicable well permits(i.e.County,Slate,s Variance,Injection,etc.)
ft. ft. in,
3,Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
fL ft.
❑Agricultural ❑Municipal/Public �•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 It. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MIATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillroek type,grain size,etc
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 ft Brown Dirt
12/22/21 14 fL 36 ft. Brown Rock
4.Date Well(s)Completed: Well iD# 36 ff 600 ft- Blue Rock
$a,Well Location: ft. ft.
Rebecca Nelson ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
Macedonia Church Rd, Monroe 28112 Seams:70', 125', 146', 150'=1g, 156',
It. fL 325',363',367',455',470',560',585'
Physical Address,City,and Zip 21.REMARKS
Union 04-114-017F
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 1/20/22
Signs a ofCertitied Well Contractor Date
6.1s(are)the well(s): [OPermanent or ❑Temporary By signing this form,1 hereby certify that the we//(v)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 0No copy tf this record has been provided to the well inner
lfihis is a repair,Jill out known well construction information and explain the nature of the
repair under;721 remarks section or on the back of ibis 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
SUBMITTAL 1NSTLJCTiONS
submit one form.
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdijferenl(example-3@200'and 2@100') construction to die following:
10.Static water level below top of casing: 120 (ft.) Division of Water Resources,information Processing Unit,
Ifwaterlevel is abm•e casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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 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 health department of the county where
constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013