GW1-2021-05877_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 FRO ATE TO R ZONES DESCRIPTION
Well Contractor Name RIP333 ft. 340 ft 1 gpm
4070-A O 9 2021 ft ft j
NC Well Contractor Certification Number Ju L 15.OUTER CASING for multi cased wells OR LINER if a livable
UOj FROM TO DIAMETER TfII['KNFcc tiiATERUIL
Derry's Well Drilling, Inc. J 1 rD��rl rC� ` 9 06.INNERCASINGORTUBING eothermaldosee ft- 161/8 d-oop PVC
Company Name ,� `t FROM TO DIAMETER� THICKNESS MATERIAL
2.Well Construction Permit#: 21-176 ft. ft. in.
List all applicable well permits rt.e.County,State,Variance,Injection,etc.)
R. ft. 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) ❑Residential Water Supply(single)
ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL. EM PLACEM ENT METHOD&AMOUNT
Cliff i ation 0 ft 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM [t. TO ft. DiATERLIL EMPLACEMI NT METHOD
❑Aquifer Test ❑StormwaterDrainage ft fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain sim etc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft. g ft Red Clay
5/28/21 9 ft 18 ft. Brown Dirt
4.Date Well(s)Completed: Well iD# 18 ft. 565 ft- Slate
5a.Well Location: ft. ft.
Bobby&Tiffany Robinson ft ft
Facility/Owner Name Facility iD#(if applicable) ft ft
Seams:56',89', 114',265',333'=1g,445'
4616 Old Pageland Monroe Rd, Monroe 28112 rt ft
Physical Address,City.and Zip 2I REMARKS
Union 03126017A
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) 22.Certification:
N W
,L 6/21/21
Signature o'-ertitied Well Contractor Date
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6.Is(are)the welt(s): (r7Permanent or ❑Temporary By signing this form, I hereby certify that the well(v)was(were)constructed in accordance
with 15AW AC 02C.0100 or 15A NCC 02C.0200 Well Construction Siandards and that a
7.Is this a repair to an existing well: ❑Yes or ONO 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 t 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.
Nor multiple injection or non-water supply wells ONLY with the.same construction,you can
.submit one farm SUBMITTAL iNSTUC IONS
9.Total well depth below land surface: 565 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdifferent(example-3@200'and tea 100') construction to the following:
10.Static water level below top of casing: 49 (ft) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: Tn 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.) 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) 1 Method of test: Air 24c.For Water Supply&Injection wells:
Also submit one copy of this form i 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.
Farm OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources ! Revised August 2013
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