GW1-2023-01666_Well Construction - GW1_20230214

I /
WELL CONSTRUCTION RECORD
For Internal Use ONLY: I �
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune cutt 14.WATER ZONES R I
9 Y �,}' r'^ �'a i FROM TO I DESCRIPTION
Well Contractor Name _ �P � _ �. ?a 469 ft 475 ft' 1/29pm
4070-A FEB ti ft ft
NC Well Contractor Certification Number 2023 15.OUTER CASING for multi-cased wells OR LINER ifa livable
' /nfL'a(i�.'-;7u`�,ll FROM TO DIAMETER THIC[aVESs •MATERIAL
Denys Well Drilling, Inc. i�n:P 0 46 ft.
61/8 i° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eo'thernral closed-loop)
22-002 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(r.e.County,Slate,Variance,Injection,etc.)
3.Well Use(check' ft ft. in
well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER I SLOTSIZE I THICKNESS I nL1TERIAL
❑Agricultural ❑Municipal/Public ft it in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERUIL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 fit- Bentonite Pumped
Injection Well; ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
[]Aquifer
TO Aquifer Storage and Recovery ❑Salinity Barrier it. ft. MATERIAL, I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft. !
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional she if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM . TO DESCRIPTION color,hardness,saillrock type.grain sim,etc.
[]Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 H. 13 ft. k Brown Dirt
9/6/22 13 ft. 21 f. Brown Rock
4.Date Well(s)Completed: Well ID# 21 ft. 600 ft it Slate
5a.Well Location: FL ft
Tracey Harrill % ft
Facility/Owner Name Facility ID#(if applicable)
E. Brief Rd., Monroe 28110 it ft Seams:59',77',121',134',155',414',
f1Lrt ii 469'=1/2 gpm
Physical Address,City,and Zip '21.REMARKS
Union 08063007E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
ffi
N W D � 9/30/22
Signature o Certified Well Contractor Date
6.Is(are)the well(S): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C1.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 ',
repair under#21 remarks section or on the back of thisform. 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 and t. additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS '
i
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 if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 150 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center;'fRaleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Infection Wells ONLY: In Iladdition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: I
12.Well constriction method. g=
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centr,:Raleigh 9,NC 27691636
13a.Yield(gpm) 1/2 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form w'thin 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 of Environment and Natural Resources—Division of Water Resources Revised August 2013