GW1-2022-10065_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION .
Well Contractor Name ?' 119 rt 124 tr• I 5 gpm
4070-A NOS nzz 189 ft 195 fr. 40 9PM
NC Well Contractor Certification Number I&OU_TER.'CASING'for multi cased wens OR LINER ifj licable
a uri6t FROM TO DIAMETER I TIHCKNESS MATERIAL
Derry's Well Drilling, Inc. �; ' �� o ft- 145. tr 6 1/8 f: SDR 21 PVC
Company Name 16.INNER CASING OR ING1girithirnial closed loo
21-376 FROM TO DIAMETER : THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft I'is
List all applicable well 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 TmCI(NESS MATERIAL
It. ft in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL : EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 It- Bent.Chips Gravity
Non-Water Supply Well:
0.Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft is
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT 11iETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional`sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,baHness,saillrock type,grain sim,etc.
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 & 11 ft. j' Red Clay
4.Date Well(s)Completed: 4/14/22 Well EN11 ft. 18 ft. ' Brown Dirt
18 ft 205 & Slate
5a.Well Location: & ft
Charles&Patricia Walton %
Facility/Owner Name Facility ID#(if applicable) p
2626 Farm House Ln, Monroe 28110 fr' & Seams: 55',59',76',111', 119'=59,
rt. ft. �; 189'=409
Physical Address,City,and Zip 21.RENIARKR,"
Union 09348209
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient)
N W �7'""' '�'' I 5/2/22
Signature HCertiSed Well Contractor 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 ISA NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standtrdr and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 eoustructed: 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:205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3@200'and 2@100) construction to the following:
1
10.Static water level below top of casing: 15 (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 Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 45 Method of test: Air 24c.For Water Supply&Injection We11s:
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