GW1-2023-01667_Well Construction - GW1_20230214

I :
WELL CONSTRUCTION RECORD
For Internal Use ONLY.
This form can be used for single or multiple well's
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 4 s' a: 3_ 130 it 136 fl. I 100 gpm
4070-A ���° ' "
t� ft. ft.
NC Well Contractor Certification Number F�L� ( n^� �s 15.OUTER CASING for multi-cased wells OR LINER if a livable
L/[ FROM TO DIAMETER' I THIC[flVM MATERIAL.
Derry's Well Drilling, Inc. M;�;T,,;,� ', o n 45 n 61/8 ;i� I SDR-21 PVC
Company Name ov'},.i,50G. �^• FROM i-'n.i 16,INNER CASING OR TUBING(geothermal closed-low
22-30 9 ' TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: fL ft, in.
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc.) �'
ft. ft. I',in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER. .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. m l)
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft it
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 fL 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft, 20 ft- Bentonite Pumped
Injection Well: ft. ft.
I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL( ERiPLACERIENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soi ack typegrain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 8 ft I, Red Dirt
9/28/22 8 ft 21 It. i Brown Dirt
4.Date Weil(s)Completed: Well II)Wt 21 ft 145 ft Slate
5a.Well Location: ft, ft "
Dekle Taylor ft. ft
Facility/Owner Name Facility ID#(ifapplicable) II
rL ft-ft
Seams:58',72',75',96', 130-136'=10bgpm
7253 Sugar&Wine Rd., Monroe 28110ft.
Physical Address,City,and Zip 21;REMARKS
Union 01195009A I'
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) oil 10/15/22
x W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that th, WIN 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 0No copy ofdtis record has been provided to the ii,'ell 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
&Number of wells constructed: 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 i
1
9.Total well depth below land surface: 145 (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 top of casing: 14 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use•"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this foma 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 276994636
13a.Yield(gpm) t00 Method of test: Air 24c.For Water Supply&Iniection 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 of Environment and Natural Resources—Division of Water Resources Revised August 2013