GW1-2022-10082_Well Construction - GW1_20221107

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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:
Dwight L. Huneycutt 14.WATER ZONES
DWI l
9 y FROM TO DESCRIPTION I
Well Contractor Name d " 4ry�„- 188 ft. 195 ft. I 1/2 gpm
4070-A C!p s,V I & ft.
NC Well Contractor Certification Number N O V p 2��� 15.OUTER CASING for multi-cased is ells OR LINER if a li-Mr
FROM TO DIAMETERI TNIC[Q11FS5 MATERIAL
Derry's Well Drilling, Inc. pr��gd��ag ll�d o ft. 53 ft 6 1/8 SDR-21 PVC
Company Name ��{ 16.INNER CASING OR TUBING geothermal dosed-loop)
22-003 FROM TO DIAMETER; TrUCKNEss MATERIAL
2.Well Construction Permit#: ft. It. ua
List all applicable well permits(Le.County,State,Variance,Injection,etc.)
tt ft in.'
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. iG in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ZIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft' 3 B- Bent.Chips Gravity
Non-Water Supply well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO fr. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. h
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness saitlrock a etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 7 ft. Red Dirt
4.Date Well(s)Completed: 7/20/22 Well II)# 7 ft. 21 ft. Brown Dirt
21 ft- 28 ft. {I Brown Rock
Sa.Well Location:
28 ft. 600 fr. Slate
Tracey G. Harrill % &
Facility/Owner Name Facility ID#(ifapplicable)
E. Brief Rd., Monroe 28110 ft. f° Seams:58',71', 127', 188'=1/2gpm
It. ft. �! '
Physical Address,City,and Zip 21.REMARKS
Union 08063007B
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 '�'"' J Gu20'c/ 4/30/22
Signature of ertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certify that the rvel!(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 ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain(he nature of the
repair under#21 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
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 INSTUCTIONS
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 100 (ft) Division of Water Resour11 ces,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: 14 addition to sending the form to the address in
Rotary 24aabove, 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
r
13a.Yield(gpm) 1/2 Method of test: Air 24c.For Water Supply&Inlection 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-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013