GW1--01917_Well Construction - GW1_20240325

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' ' - -
r' �^-'^+ FROM TO DESCRIPTION'
Well Contractor Name c d t Lr L.>~ o C"b.,y 345 ft' 350 tt• I . 2 gpm
2465-A MAR 2 (d24 447 tL 450 ft. I 1 gpm
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number FROM TO DIAMETER' , THICKNESS MATERIAL
Derry's Well Drilling, Inc.n�`" " •- ?.-v - rir:;UaX 0 tt• 47 n• 6 1/8 -'� SDR-21 PVC
ry g, DANCZaa
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-193 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fe, ft. j in:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. 1 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) IDResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial :Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irr gation 0 ft. 3 fc Bent.Chips Gravity
Non-Water Supply Well:
3 tt• 20 ft, Bentonite Pumped
❑Monitoring ❑Recovery
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
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft, Brown Dirt
4.Date Well(s)Completed: 10/28/23 well ID# 25 ft' 40 ft• Junky Shale
40 ft" 520 ft• Slate Rock
5a.Well Location: ft. ft.
Grant Winchester
Facility/Owner Name Facility MO(if applicable) f t. ft* Seams:95', 120', 133', 145', 196',215',230',
ft . f• 235',265',288',305',345'=2g,355', •
5714 Armfield Mill Rd., Monroe 28112
ft. ft. 447'=1g
Physical Address,City,and Zip 21.REMARKS
Union 04-123-017B
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) n / , l '
N `,Ir . 4 - (�f/. 11/10/23
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certijty 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 ENo 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 the same construction,you can
submit one form SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 520 (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@I00' construction to the following:
1'
10.Static water level below top of casing: 30 (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 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: G
(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
132.Yield(gpm) 3, 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
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