GW1-2023-01670_Well Construction - GW1_20230214

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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 MATER ONES TO DEst]tIPTION
Well Contractor Name $5 ft 90 ft. 5 gpm
4070-A Ot 129 ft 135 it 10 gpm
NC Well Contractor Certification Number 23 FEB15.OUTER'CASING for multi-cased wells OR LINER if o Grahle '
8 i ti r?� FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 0 fL 145 ft s 1/8 tfil- I SDR-21 I PVC
Company Name IniC•iAe i:it^1 �l{: ^.^r�t;rii 16.INNER CASING ORTUHING eothermalclosed-luo
22-347 D',rs.' !'; G FROM TO -DIAMETER J THICHNESS MATERIAL
2.Well Constructiod Permit#: ft. ft. in.
List all applicable well rmits(i.e.County,State,Variance,Injection,etc.)
ft ft. irt.
3.Well Use(check fell is
17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
+❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Head g/Cooling Supply) DResidential Water Supply(single) ft. ft in
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❑IndustriaUCommer ral ❑Residential Water Supply(shared) `1s:GROUT:.
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
d7hri ation 0 fI. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring I ❑Recovery 3 ft 20 fL Bentonite' Pumped
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater,Remediation 19.SAND/GRAVEL.PACK if a livable
❑Aquifer Storage anc Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Tee ology ❑Subsidence Control
J 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRTPTION color,hardy soil/rock a size,etc.
❑Geothermal eatin Cooling Return ❑Other explain under#21 Remarks) 0 ft- 7 ft j. Brown Dirt
7 fL 15 & j Brown Rock
4.Date Well(s)Com leted: 11/1/22 Well ID#
15 ft 205 it" i; Slate
5a.Well Location: ft. ft
Matthew Kobe ra
M ft
Facility/Owner Name Facility ID#(ifapplieable) ft ft
7419 Tesh Rd4 Monroe 28110(Crenshaw Loche, Lot 1) n Seams:56±,73',78',85'=5gpm,129'=logpm
Physical Address,City,Ad zip 133, 154'
21.REMARKS
Union 08153016
County Parcel Identification No.(PIN)
5b.Latitude and Lo)gitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one law on�is sufficient)
N W 12/1/22
Signature o Certified Well Contractor Vi Date
6.Is(are)the wells): OPermanent or ❑Temporary By signing this form,I hereby certify that the"ivell(s)was(were)constructed in accordance
with 15A NCAC 62C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to n existing well: ❑Yes or l INo copy of this record has been provided to the wed owner.
If this is a repair,fill oui)ommvn well construction information and explain the nature of the
repair under#21 remarks)section or on the back of this form. 23.Site diagraut or additional well details:
IYou may use the back of this page to provide additional well site details or well
8.Number of wells cgnstructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or,ion-ivater supply wells ONLPwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all Oths ifdifferent(axample-3@200 and 2@100) construction to the following: i
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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ll.Borebole diameter• (in-) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm)
15 Method of test: Air 24c.For Water Supply&Injection 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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