GW1--07694_Well Construction - GW1_20231122

i,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Dwight L. HuneCutt • 44.WATER ZONES'; . t I
) FROM TO DESCRIPTION
Well ConiractorName 202 ft 210 ft 1 . 3 gpm •
4070-A ft. ft. !
NC Well Contractor Certification Number '15.:OUTER CASING(for multi-cased,wells)OR LINER(if ap licable)
FROM TO DIAMETER i. THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 44 ft 6 1/8 n-, SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-385 FROM TO DIAMETER I THICKNESS MATERIAL i
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
❑Agricultural OMunicipal/Public ft ft in N 1
❑Geothermal(Heating/Cooling Supply) PJResidential Water Supply(single) ft ft in.
18.GROUT
❑InduStriaUtn Comercial OResidential Water Supply(shared) FROM TO- MATERIAL EMPLACEMENT METHOD&AMOUNT
°Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery • 3 ft 20 ft Bentonite,'. Pumped
Injection Well: ft ft .
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. -
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)°
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft 12 ft ;; Brown Dirt
9/12/23 12 ft 400 ft Slate
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft•
Emerald Pointe Realty ft ft
Facility/Owner Name Facility ID#(if applicable)
ft. f` Seams:55',ss',93',197',202'=3gpm
7815 Haigler Gin Rd., Monroe 28110 (Lot 5)
ft ft.
nt
Physical Address,City,and Zip z. /t
_
Union 08-039-012H
:
County Parcel Identification No.(PIN) I y V J 1(l��
.21iREMARKS ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 4
22.Certification: I Irh3; .._.;s.1 ;I,---,oY-?:.., .,,,
(if well field,one lat/long is.sufficient) // ... - ._�%; a
.L. 10/s/23°i s' 1i a.,
N W
Signature of ertified Well Contractor Date
6.Is(are)the well(s): VIPermanent or °Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards 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 1121 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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
6 (in.) 24b.For Injection Wells ONLY: Iniaddition 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:
(ie.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
I :
3
13a.Yield(gpm) , Method of test: Air
24c.For Water Supply&Injection Wells:
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 healtli department of the county where
constructed.
Form GW-1 NorthCarolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013