GW1-2021-00822_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
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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
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013