GW1-2023-01621_Well Construction - GW1_20230214

i
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt F4.WATER ZONES I i
FROM TO I DESCRIPTION
Well Contractor Name 158 ft 162 ft• I 3 gpm
2663-A a�I—, 250 % 255 ft 4 9Pm
NC Well Contractor Certification Number yl ���� 15.OUTER CASING for multi-casedtvells ORLINER ifa licable
FEBD 1 �. FROM TO DIAMETER I TIDCIINFSS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 47 ft 61/8 ! SDR-21 PVC
Company Name In?vir;ae:Cl : s"" Ci;:F?� 1.1n i 16.INNER CASING ORTUBING(geothermal closed-loop)
22-98 I—Ik"`OYE OG FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
& % i,in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM' To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fr 3 fr• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite Pumped
Injection Well: ft. It. j
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM I TO MATERIAL: I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. i
❑Experimental Technology ❑Subsidence Control ft.
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION tolor,hardness,soil/rock typt n sire,eta
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 ft. Red Dirt
4.Date Well(s)Completed: 9/17/22 Well i>a# 5 f t 10 ft Brown Dirt
10 ft 305 ft Blue Rock
Sa.Well Location: ft_ ft
Bill Over
fc fr. Seams:.53',69',76',95', 105',121', 130',
Facility/Owner Name Facility ID#(if applicable) ft ft.
3048 Austin Chaney Rd., Monroe 28110 ft. ft 136', 151', 158'=3gpm, 175', 190', 196'
250'=4gpm
Physical Address,City,and Zip 21•REMARKS
Union 08-051-001 D
County Parcel Identification No.(PIN)
I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one lat/long is sufficient) Diu
N W D y 10/2/22
Signature of 'fled Well Contractor Vj Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(k)was(were)constructed in accordance
with 15A 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 ONo copy oftids 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 INSTUCTIONS
9.Total well depth below land surface: 305 (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@100) construction to the following:
10.Static water level below tap of casing: 31 ({}) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: Iniaddition to sending the form to the address in
Ota 24a above, also submit a copy of this form
rm within 30 days of completion of well
12.Well construction method ry 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 Centi r l Raleigh,NC 276994636
24c.For Water Supply&Iniection Wells:
13a.Yield(gpm) 7 Method of test: Air ;
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 heal i department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013