GW1-2023-02654_Well Construction - GW1_20230411

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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 FFa.WATER ZOOMDESCRIPTION
Well Contractor Name 150 ft 155 ft. 2 gpm
4070-A 456 ft• 461 fL 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM I TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. A PR 1 2023 0 ft 45 ft. 61/8 in SDR-21 PVC
Corn art Name tli .i';.; ,:,. 16.INNER CASING ORTUBING(geothermal closed-loop)
p y `'� '�' ?s^ FROM TO DIAMETER THICKNESS MATERIAL
>3,.11.:
2.Well Construction Permit#: 22-216 -�' �?,' ' ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,eta)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑IndustriaUCornmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACE%IEN'T 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACF.MENTMETHOD
❑Aquifer Test ❑Stortmvater Drainage
ft. ft.
ElExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock in size,eta
❑Geothermal(Heating/Cooling Return) COther(explain under 421 Remarks) 0 It- 26 ft. Brown Dirt
1/10/23 26 fL 150 fL Gray Granite
4.Date Well(s)Completed: Well ID#
150 fl- 270 ft- Slate
Sa.Well Location:
270 ft. 485 ft. Granite
Pei Hong Luan ft. ft.
Facility/Owner Name Facility IDk(ifapplicable) ft. ft. Seams:49',56',75',111', 150'=2gpm,
1017 Dewitt Helms Rd, Monroe 28112 ft. ft. 270',456-461'=4gpm
Physical Address,City,and Zip 21.REMARKS
Union 04-204-027B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 2/8/23
Signature of Certilifd Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this fora.I hereby certify that the ivell(s)ivas(mere)constructed in accordance
irilh 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 91No copy ofthis record has been provided to the irell amner.
If this is a repair,fill out knonvn well construction information and explain the nature of the
repair under 421 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
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[pith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple mel/s list all depths if dQerent(example-3Q200'and 2 u@�100) construction to the following:
10.Static water level below top of casing: 50 ([t,) Division of Water Resources,Information Processing Unit,
Ifivater level is above caving,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
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013