GW1--05031_Well Construction - GW1_20230804

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
Y FROM TO DESCRIPTION
Well Contractor Name 1:��-^y 8,.,,p^ 53 ft. 60 ft. 10 gpm
2465-A 114—t•-' ; i/f 0 160 R• 165 ft. 10 gpm
NC Well Contractor Certification Number A U
u 2023"' 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
OFROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 47 it 61/8 in. SDR-21 PVC
)n`"'^.v.`s i I t-rC• 16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name 415r � �° /Un FROM TO DIAMETER THICKNESS MATERIAL
`�JV
2.Well Construction Permit#: 22-124 ft. ft. in.
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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 itBentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM _ TO MATERIAL EMPLACEMENT METHOD
g ty ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) •
-
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 7 ft. Red Dirt
3/25/23 7 ft. 185 ft• Blue Slate
4.Date Well(s)Completed: Well 1D#
ft. ft.
5a.Well Location: ft. ft.
Nhia Lor ft ft.
Facility/Owner Name Facility 1DN(if applicable)
8009 Unionville Brief Rd, Monroe 28110 (Lewis, Lt1) ft. "' Seams:53'=1ogpm, 144, 160=10gpm
ft ft.
Physical Address.City,and Zip 21.REMARKS
Union 08120029
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ', l
N W a/. 4/15/23
Si titre of Certified Well Contracto Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby term fy that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7,Ts 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 h formation and explain the nature of the
repair under 42l remarks section or on the back of this fornr 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifferent(example-3@,200'and 2Q100) construction to the following:
10.Static water level below top of casing: 26 (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 Injection Wells ONLY: In 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: ry 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 m 20 Method of test: Air 24c.For Water Supply&InjectionIWells:
(gpm) Also submit one copy of this form within 30 days of completion of
Granularwell construction to the county health department of the county where
13b.Disinfection type: Amount: 1/2 lb. I
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013