GW1-2021-04517_Well Construction - GW1_20210429

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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:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 416 ft' 425 ft' 10 gpm
4070-A Sirs' n. rt.
2�21NC Well Contractor Certification Number n p Q 15.OUTER CASING far multi cased wells OR LINER if a licable
Nr 1` FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ginguni 0 rt. 60 rt• 61/8 1O SDR-21 PVC
Company Name �G(Ci 3 1�C r!On 16.INNER CASING OR TUBING(geothermal closed-loop)
In D�t4R Jew FROM TO DIAMETER t THICKNESS MATERIAL
2.Well Construction Permit#: 20-585 ft. ft. in.
List all applicable well permits(i.e.County State,Variance,Injection,etc.)
fin•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLAMETER SLOT SIZE THICKNESS MATERIAL
tt. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 35 fL Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable.)
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soit/mck type, in size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 21 ft. Brown Dirt
4.Date Well(s)Completed: 1/18/21 Well ID# 21 tt. 28 Brown Rock
Brown
28 rt. 445 ft. Slate
5a.Well Location:
Jonathan Meek
Facility/Owner Name Facility ID#(if applicable) R ft
Sincerity Rd., Monroe 28110 Seams:75',82', 135', 188',210',290',
rt. rt. 416'=109
Physical Address,City,and Zip 21.REMARKS
Union 08078016
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 L�L. 2/1/21
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary BY signing this form,I hereby certify that'!he uvell(s)was(mere)constructed in accordance
with 15.4 NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to the mell omner.
Ifthis is a repair,fill out known mell construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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+yells ONLY mith the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple mells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
45 Division of Water Resources,Information Processing Unit,
(ft.)
If mater level is above casing,use"+" 1617 Mail Service Ce iter,Raleigh,NC 2 769 9-1 6 1 7
11.Borehole diameter: 6 (in.) 24b.For Inicetion Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of thisform within 30 days of completion of well
12.Well construction method: Rotary construction to the following: I
(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
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13a.Yield(gpm) 10 Method of test: If
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Re I sources Revised August 2013