GW1--05062_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:
Dwight L. Huneycutt 14.WATER ZONES I -
FROM TO DESCRIPTION
Well Contractor Name 168 ft' 175 ft• 5 gpm
4070-A t �t� kl9,,stlr,„ 217 ft• 225 ft• 35 gpm
NC Well Contractor Certification Number + Of .) 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic) -
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. AUG 0 A 2023 0 ft' 62 ft• 6 1/8 SDR-21 PVC
Company Name 4 16.INNER CASING OR TUBING(geothermal dosed-loop)
ifltv� 51'/:ll �r^.v,� ,�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22-•432 i31/�` � Utt ft. ft. to
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) ElResidential Water Supply(single) ft. ft. m. •
❑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:
❑Monitoring [Recovery 3 ft. 20 itBentonite Pumped
Injection Well: ft. ft.
[Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
❑Aquifer Storage and Recovery 0 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) -
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness.soilfrock type,gratin size,eta)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 12 ft. Brown Dirt
11/22/22 12 ft' 245 ft• Slate
4.Date Well(s)Completed: Well 1D# -
ft. ft
5a.Well Location: ft. ft.
Baucom Investments LLC ft. ft.
Facility/Owner Name Facility 1Db(if applicable) -
9611 Morgan Mill Rd, Monroe 28110 ft.
ft• Seams:88',95',107', 116', 168'=5gpm
g rt. ft. 217'=_35 gpm
Physical Address.City,and Zip 21.REMARKS _ --
Union 01192008
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient)
N W Gti• /—. 12/10/22
Signature Certifted Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form.I hereby cert 'that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or EINo copy alibis record has been provided to the well owner.
If lists is a repair,fill out known well construction information and explain the nature oldie
repair under a2/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 ifdifferent(example-3@200'and 2(4)100) construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
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) Method of test: Air
24c.For Water Supply&Injection Wells:
40
Also submit one copy of this fonts within 30 days of completion of
13b.Disinfeetion type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013