GW1-2022-04313_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:
John W. Huneycutt 14.WATER ZONES i.
FROM TO DESCRIPTION
Well Contractor Name 148 ft. 160 fL 20gpm
_ _41
2465-A . ft. ft.
15.OUTER CASING for multi cased wells OR LINER if a livable
NC Well Contractor Certification Number r, 7 FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. �'� 0 1D o fL 47 ft- 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-275 =' _' FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: :•s�.�r,' !' 1 ; i i1J`. ft ft iin.
List all applicable well permits(i.e.County,State,iva1 Ian e,'/rejection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
fL fL in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 iL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 fr. 35 It- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM rt TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock type,VWn skz,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It. 9 ft. Brown Dirt
2/19/22 9 ft. 21 ft Brown Rock
4.Date Well(s)Completed: Well UN ,
21 ft• 185 ft Blue Rock
5a.Well Location: ft. ft.
Brian Benton/Emerald Pointe Realty ft. ft.
Facility/Owner Name Facility iD4(if applicable)
ft. ft Seams: 88',95', 115', 169'=40g
1011 Roanoke Church Rd., Monroe 28110 (Lt 4) ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 09210015F
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iatilong is sufficient)N W 9�/ a GCJ2Q,r: 3/11/22
Signa0e of Certified Well Contractor Date
6.IS(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cerit(y that the well(s)was(were)constructed in accordance
with!SA NCAC 02C.0100 or 15A NCAC 01C.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.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under 421 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
S.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 INSTUCI•IONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing 18 (ft) Division of Water Resources,Information Processing Unit,
ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: Iit 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 Injextioe Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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. E
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013