GW1-2023-02639_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FR WATER z WO DESCRIPTION i
Well Contractor Name t 90 ft 95 ft 1 gpm
4070=A "^' - , ,!- s� 172 n' 180 ft' I 5 gpm
NC Well Contractor Certification Number /I p n y r is.OUTER CASING for multrcased welts)OR-1_ if n licable
APR ( ! �n�� FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 45 ft- 161/8 , SDR-21 I PVC
-": ) 16.INNER CASING OR TUBING(eotherntal closed-loop)
Company Name , ,.-.�,,..�;',��"�n:d i�f is i FROM TO DIAMETER in.
MATERIAL
22-443 ��
2.Well Construction Permit#: ft ft in.
Lest all applicable well permits(t.e_County•Stare,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): M SCREEN
Water Supply Well FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. It in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soitlmck type,grain Arm elc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 7 ft Red Dirt
2/8/23 7 ft 19 ft. Brown Dirt&Rock
4.Date Well(s)Completed: Well 1D#
19 ft. 265 ft Slate
5a.Well Location: ft ft
Rodney Pierce f, ft.
Seams:55',71',90'=1gpm, 109',
Facility/Owner Name Facility ID,#(if applicable) % ft
7914 Haigler Gin Rd., Monroe 28110 m ft. 172'=5gpm
Physical Address,City,and Zip 21.REMARKS
Union 08-015-001 E
County Parcel identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:(if well field,one lattlong is sufficient)
N W . r r 2/14/23
Signature ofCcifified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certo,that the reell(s)was(were)constructed In accordance
with ISA 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 END copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction h formation and explain the nature of the
repair under=21 remarks section or on the back ofthis form. 23.Site diagram or additional well detalls:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
ror multiple h#ectimt or non-water supply we//.s ON/.Fwith the same construction,you can
submit one form. SUBMITTAL TNSTUCTTONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple we/Ls list all depths ifdifferent(example-3@200'and 2@700') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
If Ivater level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lniection Wells ONLY: In addition 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
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 27699-1636
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13a.Yield(gpm) 6 Method of test' Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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