GW1-2022-04271_Well Construction - GW1_20220408

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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:
John W. Huneycutt FR WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name 109 fit• 115 fit 5 gpm
2465-A 138 f° 145 ft. 10 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL.
Derry's Well Drilling, Inc. 0 ft. 45 ft. 6 1/8 i° SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
21-264 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. IM.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc)
fit. fit. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
131tri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Carapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
rier fit TO MATERIAL. I EMPLACEMENT METHOD
R
❑Aquifer Test ❑Stormwater Drainage
fit. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,haNness,soiltrock type,grain sFa etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 12 ft. Brown Dirt
12/23/21 12 fL 26 ft. Brown Rock
4.Date Well(s)Completed: Well i1)# 26 ft. 185 ft. Blue Rock
5a.Well Location: fir. fit.
Lanes Creek Farms, LLC fL fL
Facility/Owner Name Facility ID#(if applicable)
rt. fL Seams:74', 101', 109'=5g, 138'=10g
5728 Hwy 601 S, Monroe 28112 ft. ft.
Physical Address,City.and Zip 21.RF.MARKR N a F
Union 03-177-015 202?
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce fication:
(ifwell field,one lat/long is sufficient) W �' .r = -•; ^.
N W 4f20/22 1„I
Signal ot'Certified Well Contractor V Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this farm,1 hereby certify that the wel/(v)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A Nt:AC 02C.0100 Well Construction Siondards and that a
7.is this a repair to an existing well: ❑Yes or ❑No 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�i21 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL fNSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths tfderenl(example-3@200'and 2@100') construction to dte following:
10.Static water level below top of casing: 32 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is abeme casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For Iniection 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
15 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013