GW1--07682_Well Construction - GW1_20231122

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 _
g Y FROM TO DESCRIPTION '
Well Contractor Name 152 ft 154 ft I 2 gpm
. 4070-A 195 ft 200 ft I ; 18gpm
NC Well Contractor Certification Number l5.OUTER CASING(for multi-cased wells)OR LINER(if ap Beale) .
FROM TO DIAMETER i THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 46 ft 61/8 i°• SDR-21 PVC
Company Name -16.INNER CASING OR TUBING(geothermal closed-Loop) ;, '
23-143 FROM 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. U.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in. i
❑Agricultural OMunicipaUPublic .
0 Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft. . in. i
❑IndustriallCommercial ❑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 ft Bentonite I. Pumped
Injection Well: ft. ft .
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL,PACK(if apphicable)`
FROM TO MATERIAL ; EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. II
❑Aquifer Test oStormwater Drainage
ft. ft.
❑Experimental Technology ❑subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) °.
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. i ' Brown Dirt
7/27/23 9 ft 23 ft Brown Rock
4.Date Well(s)Completed: Well ID#
23 ft 225 ft• Slate
5a.Well Location: ft. ft.
Jose Figueroa ft ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:129-137', 152'=2gpm,
902 Bruce Thomas Rd, Monroe 28112 ft. ft 195=18gpm
Physical Address,City,and Zip
Union 04-117-012 •'T'
21.REMARKS •. ,
County Parcel Identification No.(PIN) i I Y()4 7 ZL�23
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2/Certification: ti i ;;.;; .,� �,. ,:x r;-. �,.
(if well field,one lat/long is sufficient)
/ i I q +.v..•1.n
N W
.[.. GLCL- 8/23/23 ';`�:;_'`-';,
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is 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 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: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10,Static water level below top or casing:
25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centel-,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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: Air 24ta 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