GW1--05032_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD 'For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 370 R• 380 n• 100 gpm
2465-A �^P .7-�.. -..e• ti n ' n
; 'Z C tom.+IL.. 1/ s w•
NC Well Contractor Certification Number -�✓ 15.OUTER CASING(for multi-eased wells)OR LINER(ifap.,ticable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. AUG 0. 4 2023 0 ft. 125 ft• 61/8 fil SDR-21 PVC
Company Name 16.iNNER CASING OR TUBING(geothermal dosed-loop)
23-1041" �r.tip 7rF s= 13 UR$ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rlos,5:ram : ft. ft. in.
List all applicable well permits(i.e_County,State,Variance,Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): • 17.SCREEN -
Water Supply Well: FROM , TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ORes idential Water Supply(shared) 18.GROUT •`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft• 20 n• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
•
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soi0ivck type,gain size,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 10 ft. Red Dirt
5/6/23 10 it 380 ft. Slate
4.Date Well(s)Completed: Well 1D# ft. ft
5a.Well Location: ft. ft.
Cletus E. Huntley ft ft.
Facility/Owner Name Facility tDil(if applicable) ft. ft. Seams: 150', 156', 167', 170', 195',
1117 Huntley Acres Ct., Monroe 28110 ft. ,
Physical Address.City,and Zip 240',257',270',320,370'=100gpm
21.REMARKS
Union 08114013A
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient) ll '
N W . /L a . 6/1/23
Si_.,y re of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary 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.Ts this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction blformation and explain the nature of the
repair tinder=21 remarks section or on the back of this firm. 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 INSTUCTIONS
9.Total well depth below land surface: 380 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 15 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-16(7
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
100 Method of test: Air 24e.For Water Supply&Injection Wells:
13a.Yield(gpm) 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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013