GW1--05054_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 112 fL 118 rt. 12 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft- 61/8 Ia SDP-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-29 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tL ft. ft.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
FL H. in.
:Agricultural ❑MunicipaUPublic
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) FL rt. 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 f- 20 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. rt.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 ft. Wet Brown Dirt
4.Date Well(s)Completed: 6/14/24 Well ID# 6 fL 16 ft• Brown Dirt
16 ft. 200 ft• Slate
5a.Well Location: ft. ft,
Alan Schoonmaker fr. ft
Seams:7Q', 1 12'=12g
Facility/Owner Name Facility ID//(if applicable)
7609 Carriker Williams Rd., Monroe 28110 ft.
ft. ft.
Physical Address,City,and Zip 21.REMARKS ^U G J 0 624
Union 08117015G
County Parcel Identification No.(PIN) ir,`): .� ?�� ' ' "'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)N W Z'w/t}-
7/11/24
Signature of ertified Well Contractor Date
6.Is(are)the well(s): 1t7Permanent or ❑Temporary By signing this form,1 hereby certify 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 IDNo 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 V 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
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
F'or 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,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniectioq 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
12 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
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013