GW1--07683_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.WATERZONES` _, ,,, ✓'.
9 Y FROM TO DESCRIPTION
Well Contractor Name 50 ft 55 ft• 1 3 gpm
•
4070-A -_ ft. ft.
NC Well Contractor Certification Number 16.'OUTER CASING(for multi-cased wells)OR LINER(if ap licable) ;
FROM TO' DIAMETER I. THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 44 I ft 61/8 i"- SDR-21 PVC ,
Company Name •`-16.INNER CASING OR TUBING(geothermal closed-loop) . '
23-58 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. in.
3.Well Use(check well use): •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public H. ft. in I:
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s•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 ;, Pumped
Injection Well: ft. t•
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL ' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
J.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING'LOG(attach additionalsheets if necessary) ` `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soidrock type,gain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 12 ft. Brown Dirt
12 ft* 18 ft Brown Rock 1'.7".f-
$/2/23 ,; ai L.
4.Date Well(s)Completed: Well IIT#1 i
18 300 ft !, Slate • ;,
5a.Well Location: ft ft. `i. 2 2 2023
Trey Alex Mical ft . ft.
Facility/Owner Name Facility IDII(if applicable) ^� "`' 0
f
5943 Unionville Rd, Monroe 28110 t ft Seams:50'=3gpm,94',99'
ft ft. i
Physical Address,City,and Zip 21.RE111ARK5
Union , 08126012G
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one lat/long is sufficient) I'
N W Z7 � 8/23/23
Signature o Certified Well Contractor I Date
6.Is(are)the well(s): 121Permanent or OTemporary By signing this form,I hereby certt&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 ElNo 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 I
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: 300 (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@100) construction to the following:
10.Static water level below top of casing:
36 (ft.) 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 •(nj)` 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:
(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) 3 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