GW1-2021-04549_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
J FROM TO DESCRIPTION
Well Contractor Name 1 330 n• 335 n 1 gpm
4070-A Q�R 9 201 5 n. 380 n 2 gpm
NC Well Contractor Certification Number P oce�su�9 15.OUTER CASING for multi cased wells OR LINER If a Ilcable
Derry's Well Drilling, Inc. %c,1cc�3t�� r on FROM To DIA11fETER TfficxNEss 11L1TERIAL
��NIRSe ' 0 n 52 n 61/8 1n SDR-21 PVC
Company Name /► 16.INNER CASING OR TUBING eothermal closed-loop)
-1I�0 FROM TO DIAMETER TEE100'ESS MATERML
20
2.Well Construction Permit#: 8
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 TMCKMS MATERIAL
❑Agricultural ❑Municipal/Public n n.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n n• tn.
❑Industrial/Commemial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑In'i ation 0 n. 3 n. Bent.Chips Gravity
Non-Water Supply Well: g n• 35 n Bentgnits Pumped
❑Monitoring ❑Recov
Injection Well: n• n•
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity FROM Barrier ft. TO n. 11IATERL4I. I EMPLACEMENT METHOD
❑Aquifer Test ❑Strnmwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional Sheets If necessary)
❑GCothemlal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solUrock fte,train sin etc.
❑Geothermal (Heating/Cooling Return ❑Other lain under#21 Remarks 0 n• 14 n Brown Dirt
12/22/20 14 n• 400 n• Slate
4.Date Well(s)Completed: Well 1(D#
n. n.
5a.Well Location:
Aaron Webb n• fL
Facility/Owner Name Facility ID#(if applicable) n. n. Seams: 55% 116',330'=1 g,375'=2g
7515 Carl Palk Rd, Monroe 28110
Physical Address,City,and Zip 21.REMARKS
Union 01234003C
Corny Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certhtication:
(if well field,one lat/long is sufficient)
Signature o Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Constntction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No 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#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.
For multiple injection or non-water supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 36 (}�•) Division of Water Resources,Information Processing Unit,
If iwter level is above casing,use"+' 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: 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 Mall Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Fonn OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013