GW1-2023-02658_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:
FR
Dwight L. Huneycutt WATER ZONES
- �� —'-'•�-, FROM TO DESCRIPTION I
Well Contractor Name 670 ft 680 fL I 4 9pm
4070-A APR j (�7? ft. ft.
NC Well Contractor Certification Number 20L 3 15.OUTER CASING for multi-cased wells'OR LINER if a licable
FROM TO DIAMETER THICFaIESS MATERIAL
! her.;:::; -, I 0 ft. 54 ft 61/8 is SDR-21 PVC
Derry's Well Drilling, Inc. ;_,�,.�.. ::� ;,�:�
Compaq Name J `` 16.INNER CASING OR TUBING(geothermal closed-loop)
21-274 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: & ft in
List all applicable well permits(i.e.Cotmry.State,variance,Injection,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 23Residential Water Supply(single) % ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 20 rr. gentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a iicablc
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
[]Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 0 ft 18 ft Red Clay
4.Date Well(s)Completed: 1/12/23 Well ID# 18 ft 39 ft. Brown Dirt
39 It- 700 f- Slate
5a.Well Location: R. ft.
Matthew Winfrey ft ft.
Facility/Owner Name Facility iD#(ifapplicable)
ft. ft Seams:60',68',74',97', 134', 178',213',
Sikes Mill Rd, Monroe 28110 ft. ft. 372',670'=4gpm
Physical Address,City,and Zip
21.REMARKS
Union 08090008C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lot/long is sufficient) �
N W 2/1/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form;I hereby certify that the 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 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
S.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 INSTUCTIONS
9.Total well depth below land surface: 700 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'mid 2@1001 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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
13a.Yield(gpm) 4 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 healthl department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Re son Revised August 2013