GW1--05035_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. Hune cutt 14.WATER ZONES
Y w ,.� - FROM TO DESCRIPTION
Well Contractor Name `L L 4.....Li o tf' 1 57 ft 60 ft ' 75 gpm
2465-A ft. ft. ,
NC Well Contractor Certification Number A U G 0 4 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM _ TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. inhrrr":icn Pr^;,gC.,?c���, 0 ft- 45 ft-- 6 1/8 tn. SDR-21 PVC
Company Name DVAiar004..ri 16.INNER CASING OR TUBING(geothermal closed-loop)
21-421 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 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
ft. ft in.
❑Agricultural ❑MunicipaUPublic
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) IS. ROUT
FROMG TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft 3„ ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge - ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT',METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft. 15 fL Brown Dirt&Rock
4.Date Well(s)Completed: 5/18/23 Well ID# 15 fr. 105 ft Slate
• ft. ft.
5a.Well Location: ft ft.
Francisco Giotto ft ft '
Facility/Owner Name Facility ID#(if applicable) ft. ft
7924 Carriker Williams Rd, Monroe 28110 (Lot 2) Seams:57-60'=75gpm,85'
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 08117020
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) g-&4IG
,JN W "'' 6/5/23
Si lure of Certified Well Conn-ado Date
6.Is(are)the well(s): ❑Permanent or ['Temporary By signing this form,I hereby certify that the wells)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 ONo 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 constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with lire same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (ft.) 24a. For All,Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing 12 (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
75 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
136.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