GW1--05048_Well Construction - GW1_20230804

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I•
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1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONE 'S
9 Y FROM TO DESCRIPTION
Well Contractor Name Pt ��g-m 91 ft 95 ft. 1 gpm (114-116'=2gpm)
4070-A '`'��'L i V.ta 157 ft 165 ft 12 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
A U G A 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 45 ft 6 1/8 1D' SDR-21 PVC
(n�""�" r'r,^,�a 16.INNER CASINGORTUBING
Company Name A " ' D!tit (geothermalclosed-loop)
ZZ-42O D1460/3( FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: it. 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
ft ft. in.
. ❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable).
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)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 23 ft Brown Dirt Rock
7/14/23 22 ft 205 ft Slate
4.Date Wells)Completed: Well ID# ft. ft.
5a.Well Location: ft it.
Joseph Dien Do • ft ft •
Seams:52',69',77',91'=1 gpm,
Facility/Owner Name Facility 1IN1(if applicable)
4504 E. Brief Rd., Monroe 28110 ft fr. 114'=2gpm, 148', 153', 15T=12gpm,
ft. ft. 190'
Physical Address,City,and Zip 21.REMARKS
Union 08066014A
County Parcel Identification No.(PIN)
513.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W P�L. 8/5/23
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifi,that the well(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 Ian existing well: ❑Yes or ]No copy of this 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#21 remarks section or on the back of this 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 with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 205 (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'and 2@100) construction to the following:
10.Static water level below top of casing: 29 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,1Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: ry construction to the following:
(ie.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) 15 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-I North Carolina Department of Environment and Natural Resources-.Division of Water Resources Revised August 2013
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