GW1--07697_Well Construction - GW1_20231122

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WELL CONSTRUCTION RECORD For Internal I rn '
This form can he used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES. - ;'�€ ' -.
g .1 FROM TO DESCRIPTION
Well Contractor.Name 269 ft' 275 ft- I 1.5 gpm
4070-A ft. fL
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-cased wells)OR LINER(if ap livable)' .
FROM TO DIAMETER i THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 45 f 9• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) °')
22-384 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit II: fc ft. I.
List all applicable well permits(.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. tn.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. I
°lndustrial/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 ft- Bentonite 1 ' Pumped
Injection Well: ft. ft.
I.
❑Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'' ' '
FROM TO MATERIAL f' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. ;`
❑Aquifer Test °Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '
'20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 fL 14 ft Red Clay
4.Date Well(s)Completed: 5/3/23 Well ID 14 ft 28 ft- i Brown Dirt
#
28 ft• 34 ft- Brown Rock
5a.Well Location: 34 ft- 500 ft- i Slate
Brian Benton ft. ft.
Facility/Owner Name Facility ID#(if applicable) •
1017 Roanoke Church Rd, Monroe 28110 ft ft- Seams:51',69',7T,89',93',127',161',
ft. ft. 269' 1 5gpm _
Physical Address,City,and Zip 21.REMARKS .' ` T 1 y fl I
Union 09210015D �' "ram
County Parcel Identification No.(PIN) j NOV 2 2 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: P ,,.;..,.-,;;,j 1,
(if well field,one hit/long is sufficient) t r:i�7��"':-.':'�� . _- �.,:� E
N W Z7GU C` 5�28/23 :L
Signature of Certified Well Contractor ( Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby serf fy 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 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#2I remarks section or on tire 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 (I
submit one form. SUBMITTAL INSTUCIIONS
9.Total well depth below land surface: 500 . (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 59 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+•, 1617 Mail Service Centel-,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel.,Raleigh,NC 27699-1636
13a.Yield(gpm) 1.5 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 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