GW1-2022-10079_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:
Dwight L. Huneycutt 14.WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name _�. S , 134 ft 140 ft. I I 150 gpm
4070-A re "R 't"� % & I 1
NC Well Contractor Certification Number 1&"OUTER CASING' for multi-cased wells OR LINER if a ficable
V V FROM TO DIAMETER 1 THICHI s MAT
ERIAL
Derry's Well Drilling, Inc. 1lrtti 0 fr. 65 1t 61/8 �-1.* SDR-21 PVC
Company Name FDi. O*1aw�:•r 16,INNER CASING OR TUBING eothermal closed-loop)
22-177 , r%A!0f l rim FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(7.e.County,State,Variance,Injection,etc.)
ft ft. I in
3.Well Use(check well use): 17.SCREEN `-
Water Supply Well: FROM TO WAMETER .SLOT SIZE I THICKNESS MATERIAL
❑Agricultural QMunicipal/Public ft ft �i_ "
❑Geothermal(Heating/Cooling Supply) KiResidential Water Supply(single) & ft I
Qlndusttial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 ft, Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑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, tt
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRLPTION color,hardness,soiUrock e,grain size,etc.
❑Geothermal(Heatindooling Return) ❑Other(explain under#21 Remarks 0 ft 13 ft. Brown Dirt/Rock
5/25/22 13 ft 145 ft- �i Slate
4.Date Well(s)Completed. Well ID#
ft ft
5a.Well Location: ft ft.
Brandon Parson ft ft i
Facility/Owner Name Facility ID#(if applicable)
724 Price Dairy Rd., Monroe 28110 ft. It Seams:,78',94', 126-130', 134'=1509pm
ry ft. ft.
Physical Address,City,and Zip
11.REMARKS.
Union 09210017
County Parcel Identification No.(PIN) �; 1
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N w � � �u�2ay�cl � 6/23/22
Signature of rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certih 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 hJNo copy ofthis record has beenprovided to the ivell owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells 0MYwitlr the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
1;
9.Total well depth below land surface: 145 (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: 10 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter- 6 011-) 24b.For Infection Wells ONLY: Iri 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
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:• 1636 Mail Service Ceni er,Raleigh,NC 276994636
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24c.For Water Supply&Infection Wells:
13a.Yield(gpm) 150 Method of test: Air Also submit one copy of this form r ywithin 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 Enviionment and Natural Resources—Division of Water Resources Revised August 2013
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