GW1-2021-05867_Well Construction - GW1_20210709

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 14.WATER ZONES
,,, FROM TO DESCRII'1'ION
Well Contractor Name 132 n 140 n I 4 gpm
4070-A 3uL 0 9 N11
NC Well Contractor Certification Number 1 UTER CASING for mWtitased wells ORrmcxiLBYE�R rf a licable
r�rOrQS PROM ro DIAMETER Ess MATERIAL
Derry's Well Drilling, Inc. 1;nf0tr 3 ,,�SgOtsOn 0 tt. 50 n 6 1/8 '1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21—35 FROM TO DLIMEItm THICHIVESS MATERIAL
2.Well Construction Permit#: n. ft. '°•
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
in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMELACEIID?NT METHOD&AMOUNT
❑Irri ation 0 n. 3 it- 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 if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control
20.DRILLING LOG Wineh additional-sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,bardness,soilfrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n' 21 ft. Red Clay
4.Date Well(s)Completed: '4'/14/21 Well ID# 21 n. 33 n' Brown Dirt
P 33 n 300 n Slate
5a.Well Location:
Brian Benton
Facility/Owner Name Facility ID#(if applicable)
n. n. ' Seams:70',76', 132'=4g
1013 Roanoke Church Rd., Monroe 28110 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 09210015E
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat(iong is sufficient)
N W T�GtrrLZ-,L.. 5/10/21
Signature clYCertified Well Connector Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the,vell(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fill out Brown well construction information and explain the nature of the
repair tinder#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
S.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: 300 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:
37 Division of Water Resources,Information Processing Unit,
(ft.)
If,vater 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:
(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
138.Yield(gpm) 4 Method of test: Air
24c.For Water Supply&Injection Wells:
Also subunit one copy of this form;within 30 days of completion of
13b.Disinfection type:
Granular Amount: 1/2 lb.
well construction to the county healih department of the county where
constructed.
Forn GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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