GW1--05049_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 ` . ..
l FROM TO DESCRIPTION -
Well Contractor Name rn ,r-. 155 ft 160 ft 6 gpm
2465-A i �1.,�L-; V I-- ft. ft.
NC Well Contractor Certification Number A U G 0 4 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Beattie)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 45 ft 6 1/8 in• SDR-21 PVC
Company Name IMormF,tiJ4S)rif,^*:14,,,:+s.D;,)n 16.INNER CASING OR TUBING(geothermal closed-loop)
22-270 DWQ/SOGFROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 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 OMunicipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑lndustriallCommercial ❑Residential Water Supply(shared) ls.GROUT
FROat TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft Bent.Chips Gravity
Non-Water Supply Well: 3 it 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 ❑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,soilrock type,grain size,etc.)
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 ft. Brown Dirt&Rock
5/19/23 15 • ft. 245 ft. Slate
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Luis& Darlene Narvaez
I Seams:65',70',75',85',95', 125', 130',
Facility/Owner Name Facility 11)4(if applicable)
ft.
ft. ft. 145',155'-160'=6gpm, 197',210'
1013 Zephyr Circle, Monroe 28110
Physical Address,City,and Zip 21.REMARKS ,
Union 09-105-004
•
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) n - •
N W gna 4: •w 6/2/23
Si of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 1121 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: 245 (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@I00') construction to the following:
10.Static water level below top of casing 33 (fit,) 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 Infection 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: ry 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