GW1-2022-10043_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
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
.to �-,^*=n p•.•'-`a FROM TO DESCRIPTION 1
Well Contractor Name r1� -_ e V K ' 375 f` 385 f" I 29pm
2465-A AI rq q fL ft. C
NC Well Contractor Certification Number NOV V 0 t L 0Z 2 15.OUTER CASING for multi cased wells OR LINER i[a Gcable
FROM TO DTAMETERi' 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. lniccPr,;3!,as,q PtO�^x'Y2:�1 Un O ft. 50 ft- 61/8 ;1D' 1 SDR-21 I PVC
Company Name L., ° 16.INNER CASING OR TUBING(geothermal closed-Ido
21-393 FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable ivell permits(1.e.County,Stale,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 ❑Municipal/Public ft ft• in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) fr ft in
❑Industrial/Commercial ❑ FR
Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 3 ft- Bent.Chips Gravity.
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 fa Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK: if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage
% ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock in size,eta
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 20 ft ; Brown Dirt
5/19/22 20 ff 545 ff Blue Rock
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Emerald Pointe Realty ft- ft.
Seams:88,93,135, 150, 170,200,,
Facility/Owner Name Facility ID0(if applicable)
ft. �
210', 1216',234',250',298',328',335',
7831 Haigler Gin Rd., Monroe 28110
Physical Address,City,and Zip 351,375'=29pm
21.REMARKS
Union 08-039-012E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient) 9��
N w 6/4/22
SignalVeofCcififiedWellContmetor ( Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 END copy ofthis record has been provided to theiwell owner.
If this is a repair,fill out known well construction information and explain the nature of the i
repair under 421 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 u
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 545 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-30_200'and 2Q100) construction to the following:
10.Static water level below top of casing: 58 ({t•) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For inieetion Wells ONLY: In addition to sending the form to the address in
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 276994636
13a.Yield(gpm) 2 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form Iwithin 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
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