GW1-2023-01675_Well Construction - GW1_20230214

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.WATER ZONES'
6 I
9 Y FROM TO DESCMTION I
Well Contractor Name - 409 ft• 415 ft I 2 gpm
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4070-A ��"�- .�, 4p' fL & k
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NC Well Contractor Certification Number 15:OUTER CASING for multi-eased wells OR LINER if a licable
FEB 2023 FROM TO DIAMETER t THIClavess MATERIAL
Derry's Well Drilling, Inc. - 0 ft 45 fL 61/8 SDR-21 PVC
Company Name " " t'C ' ?s; t 16.INNER CASING OR TUBING eotheiwal closed-loop)
Do'�,'Z;T LntY FROM TO DIAMETER THICKNESS MATERUL
2.Well Construction Permit 4: 21-387 ft & in
List all applicable well permits(1.e.County,State,Variance,Injection,etc.)
ft a 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) EIResidential Water Supply(single) ft ft in _
18.,GROUT'
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri tion 0 , ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite ;; Pumped
Injection Well: ft ft
[]Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL :' EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
30.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) []Tracer FROM To DESCRIPTION color,hardness,soit/mck a etc.
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft- 6 ft Red Dirt
4.Date Well(s)Completed: 12 I22 Well ID# 6 fL 29 fL I; Brown Dirt
29 f• 37 ft. Brown Rock
5a.Well Location: t 37 ft 600 ft Slate
Emerald Pointe Real
tY rt ft; Seams:59',67',75',98', 106',219',224'
Facility/Owner Name Facility ID#(ifapplicable) ft ft 288',266',306%340%395',409'=29pm
7827 Haigler Gin Rd., Monroe 28110 ft. ft
Physical Address,City,and Zip
21.RRMARI{$ .,
Union 08-039-012F
County Parcel Identification No.(PIN) �!
5b,Latitude and Longitude in degrees/miuntes/sec6nds or decimal degrees: 22.Certification:
(ifwell field,one hat/long is sufficient)
N W 1/4/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the'' 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 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 I
repair under B21 remarks section or on the back ofthis form. 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 attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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 oil depths ifdifferent(example-3@200'and 2@I00) construction to the following: i
10.Static water level below top of casing: 45 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,RI aleigh,NC 27699-1617
11.Borehole diameter: 6 00 24b.For Injection Wells ONLY: In addition to sending the form to the address in
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: `
(i.e.auger,rotary,cable,direct push,etc.) i,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm)
2 Method of test: Air 24c.For Water Supply&Infection 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
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