GW1-2022-04307_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt F4WATERzoNEs
FROM TO I DESCRIPTION
Well Contractor Name —� 3.( 175 ft- 185 ft 12 gpm
4070-A 'Y 311, j ft. ft.
NC Well Contractor Certification Number P 8 202? 15.OUTER CASING for mold-cased wells)OR LINER if a licahle
FROM TO DIAMETER TIHCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 46 ft- 6 1/8 SDR-21 I PVC
Company Name ^16.INNER CASING OR TUBING eothermal closed-loop)
21-396 '` FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: t 't` �" ft. ft, 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 ti. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. It. in
❑lndustriaUCornmercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 3 ft- Bent Chips Gravity
Non-Water Supply Well:
3 fL 35 ftBentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a cable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Storrnwater Drainage
ft ft.
[]Experimental Technology ❑Subsidence Control
20 DRILLING LOG attach additional sheets if ncees
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillmek type,grain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 7 ft. Red Clay
4.Date Well(s)Completed: 2/1 1/22 Well ID# 7 fL 19 ft. Brown Dirt
19 ft. 225 ft• Slate
5a.Well Location: g• It.
Ronald E. Ross ft fL
Facility/Owner Name Facility ID#(if applicable) fL
ft t. Seams: 52',56',69',74',88-91',97',
1910 Plyler Mill Rd., Monroe 28110 ft. f
113', 117-125', 175'=12g
Physical Address,City,and Zip 21.REMARKS
Union 09-330-008
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 stir � Lt GUZO.r�f lCL`� 2/25/22
Signature o Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with I5A 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 RIND 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 INSTUC IONS
9.Total well depth below land surface: 225 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:
36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary construction to the following:
(i-e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 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: 112 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013