GW1-2021-04519_Well Construction - GW1_20210429

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 150 ft 115 ft 50 gpm
4070-A % 9 2021 fL ft. I
NC Well Contactor Certification Number hN� 5,OUTER CASING for multi-casea'wells OR LINER if a licable)
Derry's
ait0 @gS1ng OM TO DIAMETER THICKNESS MATERIAL
Der s Well Drilling, Inc. r►PrO�QAd y,nn0 R 49 ft 6 1/8 1 1°• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-Ioo
20-491 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ! in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL m"
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 & 3 & Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation -19.SANDIGRAVEL`PACK if applicable)
W, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft.
MATER i
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additionsi sheets if necesaa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON color,hardness,saiurock type,Vain mize,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 26 ft. Brown Dirt
4.Date Well(s)Completed: 12/28/20 Well ID# 26 fL 125 fL Slate
ft. ft.
5a.Well Location: fL ft.
Claudia Beth McLeod % fL
Facility/Owner Name Facility ID#(if applicable) ft. fL Seams: 55', 105'=509
2040 New Salem Rd., Monroe 28110 ft ft•
Physical Address,City,and Zip 21.REMARKS "
Union 09037001
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 W 1/26/21
Signature of Certified Well Contractor Date
6.Is(are)the well(S): 101'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0N0 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 ofthe _
repair under 921 remarks section or on the back of thisform. 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: 125 (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For 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: 9 (g,) 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 Iniection Wells ONLY:I 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
13a.Yield(gpm) 50 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this forml 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