GW1--05055_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 140 ft• 145 ft. 1 gpm
2465-A . p'r• 336 ft• 340 ft I 14 gpm
NC Well Contractor Certification Number e L e 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
�) FROM TO . DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. AUG 0 g 2020 o ft. 47 it 6 1/8 SDR-21 PVC
Company Name 1niGrt 'h 16.INNER CASING OR TUBING(geothermal closed-loop)
kg.; ;i p r,t„ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22-187 (?!1. • ` `„*..,,,,, ft. ft in.
List all applicable well permits(L e.County,State,Variance,I jection,chef
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 • OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential 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
OMonitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation •19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer 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,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f4 25 ft• Brown Dirt
4.Date Well(s)Completed: 3/21/23 25 ft. 405 ft• Slate
Well ID#
ft. ft.
5a.Well Location: ft. ft.
•
Bruce Williams
ft. fr.' Seams:75',80', 110',140'=1gpm, 150', 175'
Facility/Owner Name Facility ID#(if applicable)
626 Jug Broome Rd, Monroe 28112 (Lot 2) ft' 230';235',255',270',275-280',315',
ft ft, 336-340'=14gpm,350',380'
Physical Address,City,and Zip 21.REMARKS
Union 04-123-017A
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 `1, Lt/. 4/10/23
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): l lPermanent 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 iallo 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths IIfdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bdrehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotay 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) 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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