GW1-2022-10034_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO I DESCRIPTION I
Well Contractor Name 409 ft' 415 ft• 40 gpm
4070-A
NC Well Contractor Certification Number A 10`/ y O�� 15.OUTER CASING for multi-cased wells)OR LINER if a Gcable
NOV t FROM TO DNMETER TRIC[QNFSS MATERIAL
Derry's Well Drilling, Inc. 0 fL 50 It" s 1/8 SDR-21 I PVC
Ufa
Company Name In+or-vr,u;t0"l (`' "'"r"iQ J 16.'INNER CASING OR TUBING eothermal closed-ioo
22-97 rD%NQ/s0G FROM TO DIAMETER !THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable ivell 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
❑Agricultural ❑MunicipaVPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. it. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It. 3 fl. Bent.Chips, Gravity
Non-Water Supply Well:
3 ft. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable .
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 attack additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil rock type in Sim etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fl- 12 ft. Red Dirt
4.Date Well(s)Completed: 4/11/22 Well ID# 12 ft' 19 ft. Brown Dirt
19 fr. 500 ft. Slate
5a.Well Location: & ft
Kelsey Dunlap
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:72',_s8',94', 11s', 167',214',255'
1522 Clarence Secrest Rd., Monroe 28110
ft. ft. 217',285',313',409'=40gpm
Physical Address,City,and Zip 21.RE6fARKS
Union 09411002A
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreesAninutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N
TJGAJt�'
�, 4/30/22
Signature of Cfffified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that"tire ivell(s)mvas(were)constructed in accordance
ivith 15A NCAC 02C.0100 or I5A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis 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 under#21 remarks section or on the back ofthis 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 mvith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 500 (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 2@100) construction to the following:
10.Static water level below top of casing: 15 00 Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:f f In addition to sending the form to the address in
Rotary 24aabove, also submit a copy offthis 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 Resoprcesl Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
40 Air 24c.For Water Supply&Infection Wells:
13a.Yield(gpm) Method of test:
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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources
ources Revised August 2013
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