GW1-2021-04542_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For hnemwl use ONLY:
This forur can be used for single or,multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nanne 75 n. 85 n. ; 25 gprn
4070-A 9 ft. k
NC Well Contractor Certification Number 15.OUTER CASING for molt[cased w'eBs LINER it AR a llcable
LAL
Derry's Well Drilling, Inc, n?Cecesof, 0 onI 48 ft- s 1/8 !n s R 21 DINIET ��TER PVC
Company Nanu /► c `(3;6 Ow 16.INNER CASING OR TUBING(geothermal closed-loop)
20-1 V FROM TO DL1AffiTER, TMCIUMSS MATERIAL
2.Well Construction Permit#: ft• n• in.
List all applicable well permits(i.a.Counq,,Stare,Variance,Injection,etc.) ft. ft. in.
3.Wetl Use(check well use): _17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCFLNTSS MATERIAL.
ft. n. In.
❑Agricultural ❑MunicipaMblic
❑Geothermal(Heating/Cooling Supply) ®Residential Water'Supply(single) n n• In.
❑Industrial/Comrnercial ❑Residential Water Supply(shared) 18,GROUT
FROM I TO MATERIAL: EMPLACEMENT METHOD ffi AMOUNT
❑Irri ation 0 n. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 n Bentonite Pumped
Injection Well: n. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a llcable
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO n. ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonmvater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets It necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness solUrock type,gnin sin etc.
❑Gcothetmal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 n• 8 ft. Red Dirt
12/4/20 8 ft- 27 n• Brown Dirt
4.Date Well(s)Completed: Well ID#
27 a• 125 ft- Slate
5a.Well Location:
RHH of Union LLC
Facility/Owner Nmne Facility ID#(if applicable) n. n.
Seams: 75=25g
8212 Old Ferry Rd., Monroe 28110(Old Ferry Est., Lt2)
Physical Address,City,and Zip 21.REMARKS
Union 08120038E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifleadon:
(if well field,one lat/long is sufficient) ,
N W 1/2/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary
4 signing this form,I hereby corrifi,that the tvell(s)was(were)constructed in accordance
ulth I JA NCAC 02C.0100 or 15.4 NCAC 02C.0200(fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the[cell owner.
If this is a repair,fill our known[yell consn•ucrion information and explain the nature of the
repair under#11 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 ndrh the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3C200'and 2C100') construction to the following:
10.Static water level below top of casing:
1 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+" I I$
11.Borehole diameter- 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 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
13a.Yield(gpm) 25 Method of test: Air 24c.For Water Supply&Injection Welts:
Also submit one copy of this form4 within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb, well construction to the county health department of the countywhere
constructed.
i
For,n OW-I North Carolina Departnncut of Environment and Natural Resources—Division of Water Re olrces Revised August 2013
I