GW1-2023-01673_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 I I
1.Well Contractor Information:
Derry L. Huneycutt �"�', : ' "� '"� r'"r�°s 14.WATERZONES
7 7i�e S ' .�'K_ }` �t I '•' FROM TO DESCRIPTION I
Well Contractor Name 75 ft 85 ft-
I I 1 gpm
2663-A FEB i 2023 ft. ft
NC Well Contractor Certification Number 15.OUTER CASING Ifor mmlti-rased wells'.OR LINER if a Gcable
Derry's Well Drilling, Inc. `n1 p( ti Unit FROM To DL►METER l I TmcravEss MATERIAL
nt B,� 0 ft 45 ft. 6 1/8 iR6-11 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eoth"erinal closed-loa ,
22-189 FROM TO DIAMETER '7 IMCKNESS MATERIAL
2.Well Construction Permit#: ft ft in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) M ft in.
3.Well Use(check well use): 17.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIa1FSS MATERIAL
❑Agricultural \❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt ft io
❑bidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT_FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft 3 fr. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 20 Bentonite, Pumped
Injection well: ft fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer-Storage and Recovery ❑Salinity Barrier FROM To MATERIAL L EMPLACEMENTnEETHon
fr. ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING'LUG attach additional sheets.if assess "
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soluroek in sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 30 ft Brown Dirt&Rock
9/8/22 30 ft 200 ft Blue Rock
4.Date Well(s)Completed: Well ID#
ft ft I1
5a.Well Location: ft. ft
Michael Patterson
Facility/Owner Name Facility ID#(if applicable) ft. Seams;,67',72',75=85'=1gpm,90', 112',
ft ft, 145', 150:, 16T, 1s0'
450 East Village Dr., Monroe 28112(East Village, Lot 19)
ft ft
Physical Address,City,and Zip
21.REMARKS'
Union 09-087-035
County Parcel Identification No.(P"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: j
(ifwell field,one hat/long is sufficient)
N W _.L -. �GLi r 9/30/22
Signature of C ed Well Contractor Date
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6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)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 ❑No copy ofthis 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 INSTUCTTONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,(Raleigh,NC 27699-1617
6 (in) 24a
For Infection Wells ONLY: In iddition to sending the form to the address in
11.Borehole diameter!
Rota 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:
(Le,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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 count}where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013