GW1-2021-04528_Well Construction - GW1_20210429

I
i
II
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Dwight L. Huneycutt 14.WATER ZONES ;
FROM TO DESCRIPTION
Well Contractor Name 167 It- 175 ft- I 4 gpm
4070-A ft. ft.
NC Well Contractor Certification Number ���+++"""��� 15.OUTER CASING for mu11i cased wells OR LINER if' Gcsble
9 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 157 ft- 161/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-522 PR 2 9 2021 FROM TO IA DIAMETER i THICKNESS MATERL
2.Well Construction Permit#: A 4 ft. ft. in.
List all applicable well permits(i.e.County State,Variance,Injection etc.) SS�� Ul�tl! ft. ft. in.
3.Well Use(check well use): �ri^ufll:3i W Sec
ge�tlorl 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
Olrri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 e. 35 rc. Bentonite' Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO I MATERIAL! I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,Usip size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 6 ft. Wet Red Clay
3/23/21 6 ft. 18 ft. Wet Brown Clay 8,Gravel
4.Date Wells)Completed: Well ID#
18 rt• 29 rt Junky Rock
5a.Well Location:
29 rt• 82 rt• Black Granite
Helms Partners
82 ft- 300 ft- Blue Rock
Facility/Owner Name Facility ID#(if applicable)
ft. tt• Seams: 130', 167'=4g
2604 Henry Baucom Rd., Monroe 28110 tt. rL
i
Physical Address,City,and Zip 21.REMARKS
Union 08022009J
County Parcel Identification No.(PIN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) /
�G-N N' 4/7/21
Signature Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that'the uvell(s)it-as(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constrnetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9lNo copy oflhis record has been provided to the well owner.
If this is a repair,fill wd known well 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.cells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-3C200'and 2@100') construction to the following:
I
10.Static water level below top of casing:
34 Division of Water Resources,Information Processing Unit,
(ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Ceniter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of thpis form 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
138.Yield(gpm) 4 Method of test: Air 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 lb. well construction to the county health l,department of the county where
constructed.
Form GW-1 North Carolina Department of En%ironment and Natural Resources-Division of Water Res
Iouvices Revised August 2013