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HomeMy WebLinkAboutGW1-2021-00822_Well Construction - GW1_20211208 WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: Dwight L. Huneycutt FROM ER ZONES F TO DESCRIPTION Well Contractor Name 270 ft. 280 ff 60 gpm 4070-A ft. ft. i NC Well Contractor Certification Number 15.OUTER CASING.for multi cased wells OR LINER if a livable FROM TO DIAMETER THICKNESS MATERIAL Derry's Well Drilling, Inc. 0 fL 45 ft 6 1/81- SDR-21 PVC Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 21-268 FROM TO DIAMETER! THICKNESS MATERIAL 2.Well Construction Permit#: ft. fr. 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 SLOT SIZE THICKNESS MATERIAL ft ft. in. ❑Agricultural ❑Municipal/Public ❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. ❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT- ❑Irri ation 0 It' 3 ft- Bent.Chips Gravity Non-Water Supply Well: 3 ft 35 It- Bentonite Pumped ❑Monitoring ❑Recovery Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable) FROM TO MATERIAL: EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. ❑Aquifer Test ❑Stormwater Drainage It. ft. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG'attach additional sheets if necessary) ❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCREMON color,hardness,soillmek in s' etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 6 ft. Brown Dirt 9/14/21 6 ft' 285 ft. slate 4.Date Well(s)Completed: Well ID# ft. ft. 5a.Well Location: ft. ft. Michael Watkins ft. ft. Facility/Owner Name Facility ID#(if applicable) ft ft. Seams:68',86', 108', 116',270'=609 8303 Ferguson Farms Ln, Monroe 28110 ft. ft. Physical Address,City,and Zip 21.REMARKS Union 08084001 M County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (ifwell field,one lat/long is sufficient) , N W Signature of Certified Well Contractor Date 6.IS(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify thahthe well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis 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 same construction,you can submit one form. SUBMITTAL INSTUCPIONS 9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdii ferem(example-3@200'and 1@100') construction to the following: 10.Static water level below top of casing: 15 (ft•) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 i 11.Borehole diameter: 6 (in.) 24b.For Injection 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.c.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) 60 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 department of the county where constructed. j I Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013