GW1-2022-10066_Well Construction - GW1_20221107

f
i
WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14:WATERZONEs
FROM TO DESCRIPTION]
Well Contractor Name > r a f 175 ft- 185 ft- 8 gpm
4070-A fr. ft. ( �
NC Well Contractor Certification Number NQ V 2022 IS.OUTER CASiNC for mnitl cased wells OR LINER ifa livable
FROM TO DLIM%R" THIC[CVESS AUTERiAL
Derry's Well Drilling, Inc. t roc:...^ vr�tl 0 fr. 149 ft- s v8 SDR-21 I PVC
Company Name " �^ DN?,' 16.INNER CASING ORTUItNG eothermalclosed-loop)
21-230 FRONT TO I DIAMETER': I THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable well permits{r ty e.Coun ,Stale,Variance,Injection,etc..) �'
ft. ft. i in.
3.Weil Use(check well use): 't7.SCREEN -
Water Supply Well: FROM TO DIAMETER -SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. is
❑Tndustrial/Commercial ❑Residential Water Supply(shared) ts.'GROOT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 fL 3 IL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Beritonite' Pumped
Injection Well: ft. ft. /
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a livable ,
FROM TO. MATERIAL- EMPLACEMENT METHOD
❑Aquifer Stooge and Recovery ❑Salinity Barrier ft fL
❑Aquifer Test ❑Stormwater Drainage
ft. fL �
❑Experimental Technology ❑Subsidence Control I
20.DRILLING LOG attach additionsl'sheeis if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,sailfrocktype,giviiii sim,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 f4 Red Clay
2/19/22 8 fL 19 ft. Brown Dirt
4.Date Wells)Completed: Well TD#
19 ft. 25 ft. ;: Brown Rock
5a.Well Location: 25 ft. 225 ft. Slate
Helms Partners Inc. fL ft.
Facility/Owner Name Facility lD#.(ifapplicable) ft. ft. Seams:i 58%67',75%88% 113% 175'=8gpm
2606 Henry Baucom Rd., Monroe 28110 (Lt 5) ft. ft.
Physical Address,City,and Zip 21_REMARKS
Union 08-072-009K
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one IaUlong is sufficient) z-G4}Z�� '
N w 3/29/22
Signature ot'Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing rids form,I hereby certify that the iveU{s)Ivor(mere)constructed in accordance
ivilh 15A NCAC 02C.0100 or 15A JV AC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill nut known well construction information and explain the nature of the
repair under ii21 remarks section or on lire 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 wells ONLY with the same construction,you can
submit one farm SUBMITTAL iNSTUCTTONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths fdifferenl(example-3@200'and 2«100) construction to the following: j
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,information Processing Unit,
Ifirater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241b.For iniection Wells ONLY: Tn 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.anger,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) 8 Method oftest•.Air 24c.For Water Supply&Iniection\Ve Its:
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-1 Nordt Carolina Department of Environment and Nanual Resources—Division of Water Resources Revised August 2013