Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
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