GW1-2021-05866_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal use ONLY:
This form can be used for single or multiple wells �
1.Well Contractor Information:
Dwight L. Huneycutt n r1021 14.WATERZONES
°7 / FROD1 TO DESCRIPTION
Well Contractor Name sgm9 Ulf 89 n' 300 n 5 gpm
4070-A rmat>a�proce,oil
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf li o cabte
D FROM TO DIAMETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 n 47 n 61/8 1n SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
20-552 FROM TO DIAMETER THIC'IOTESS 11iATERIAL
2.Well Construction Permit�: n. rt. `°'
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) n n. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
n. n. in.
❑Agricultural ❑Municipal/Public
❑Geothermal( eatin Coolie Supply) OResidential Water SuPP1Y(single) n. n. �•
❑hnustriaYCommercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt' 3 n Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 n 35 n Bentonite, Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fit applicable)
FROM TO MATERIAL EMPLACEMEKr METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n n
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hsrdness,wittrock size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) 0 n' 6 n Red Dirt
4/15/21 6 n 18 & Brown Dirt
4.Date Well(s)Completed: Well ID#
P 18 n• 350 n• Slate
5a.Well Location: tt. fur
Karen Hamilton
Facility/Owner Name Facility ID#(if applicable) ,
1021 Roanoke Church Rd., Monroe 28110 Seams:58',65',78',255,289'=5g
rt. rL
Physical Address,City,and Zip 21.REDIARKS
Union 09210015
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)
W 5/10/21
N
Signature of Certified Well Contractor Date
6.Is(are)the welt(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 ffINo copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#11 remarks section or on the back of this form. You
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 ivells ONLYwith the same construction,you can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 350 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[jerent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing:
34 (ft.) Division of Water Resources,Information Processing Unit,
If ivater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: 4
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Injection Wells:
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 healthdepartment of the county where
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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