GW1-2022-10049_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For internal use ONLY:
Tbis form can be used for single or multiple wells l
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES': I. %
g Y FROM TO DESCRIPTION I
Well Contractor Name o f 188 "' 195 ft. I j 10gpm
4070-A '�• a et
NC Well Contractor Certification Number N O V 0 7 2022 IS.OUTER'CASING for T!lti-cased was OR LINER if a` licable
FROM TO DIAMETER 1 TffiCIINESS MATERIAL
Derry's Well Drilling, Inc. tCl�B it i i*71 l�r^G-r gar Urta 0 ft- 46 ft• 6 1/8 SDR-21 PVC
Company Name ,D%A lQ/5.0G 16.1NNER CASING OR TUBWG(geothermal closed-loop)
20-540 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable well permits(i.e.County,Stale,Variance,Injection etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS= THICKNESS MATERIAL
ft. ft. in. �.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft tt - in. I
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL 1, EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite' Pumped
Injection well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
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a EMPLA
❑Aquifer Storage and Recovery ❑Salinity Battier FROM ft. TO ft MATERIAL CEMENT METHOD
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❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO' DESCRrPTION color,hardness,soil/rock ain shy.,etc
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft- 12 ft BroWn Dirt
12 ft- 200 ft i; Slate
4.Date Wells)Completed: 5�13�22 Well ID# ft. ft.
5a.Well Location: ft ft.
,Jason &Dana Taylor tt ft.
Facility/Owner Name Facility ID4(if applicable)
ft ft. Seams:!;58%69%77',90',115-117',125',
2608 Henry Baucom Rd, Monroe 28110 ft ft
� 151',188=10g
Physical Address,City,and Zip 21.REMARKS
Union 08-072-009M
County Parcel identification No.(PIN) 4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat(long is sufficient) b
N w
6/4/22
Signature of&ertified Well Contractor Date
6.Is(are)the well(s): 1>/7Permanent 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 END 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 421 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
S.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 I,
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@100) construction to the following: ' 1
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10.Static water level below top of casing: 22 (ft.) Division of Waterltesources,information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,iRaleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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 27699-1636
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13a.Yield(gpm) 10 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 healtl l department of the county where
constructed
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013