GW1-2022-10064_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single at multiple wells' I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
DWI
9 Y FROM TO DESCRIPTION
Well Contractor Name 229 ft. 235 ft I �, 3 gpm
4 0 rn=
4070-Aqb ft ft
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OR LINER if a livable
^O^n FROM TO DIAMETER f THICIQVESS MATERIAL
Derry's Well Drilling, Inc. NQV 'i7 L LL 0 ft• 46 ft 6 v8 1,'" SDR-21 I PVC
Company Name }fl f l�ft4 16.INNER CASING OR TUBING eothermal closed-loop)
21-3111n�u� FROM TO DIAMETER THICKNESS .MATERIAL.
Z.Well Construction Permit#: ca-1o130<3 ft. fr. li is
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOTSIZE TIHCItNES3 MATERIAL
ft. & in.
❑Agricultural 11Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. It. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is:GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 tt• 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 ft TO MATERIAL. EMPL.ACFdt1ENT METHOD ft '
❑Aquifer Test ❑Stormwater Drainage
H. ft. I. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionalsheets if necessary),
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION calo%hardness soiurock type,grain sine,etc
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 M �; Brown Dirt
4.Date Well(s)Completed: 5/12/22 Well lD# 14 ft 325 ft. Slate
& ft jt
5a.Well Location: s
ft ft It '
Jason Shulenberger ft ft
Facility/Owner Name Facility ID#(ifapplicable)
2612 Henry Baucom Rd, Monroe 28110 ft ft. Seams: 58',74',117',172',201',.
ft. j; 229-3gpm
Physical Address,City,and Zip ,r21.REMARKS'
Union 08072009E
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 ,, 6/30/22
Signature of Certified Well Contractor Date
6.1s(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby cer16 that!the wells)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 END copy of this 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 I.
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 hyection or non-water supply wells ONLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS I
9.Total well depth below land surface: 325 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 43 (ft) Division of Water Resoui ct',Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Iniection Wells ONLY: III addition to sending 11.Borehole diameter: 6 (in.) g the form to the address in
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:
(Le.auger,rotary,cable,direct push,eta) F
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 3 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 courtly health(department of the county where
constructed.
Forth GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013.
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