GW1--07686_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 -
9 Y FROM TO DESCRIPTION
Well Contractor Name- 48 ft. 52 ft 1 5 gpm (82-85'=5 gpm)
4070-A 89 ft 92 ft 5 gpm (176-180=15 gpm) _
NC Well Contractor Certification Number IS.OUTER-CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 44 ft- 61/8 ; in.. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)' - y•- - -
23-165 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counry,State,Variance,Injections etc.)
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 ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft, Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
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 OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary) --- - -- - -
0 Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 18 ft Brown Dirt
4.Date Well(s)Completed: 9/13/23 Well ID# 18 ft 185 ft Slate
ft. ft. 1.
5a.Well Location: ft. ft
Alan Caulder ft ft. Seams:48-52'=5g,61',75',82'=5g, ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft
89-92'=5g, 171', 176'=15g
7303 Tesh Rd., Monroe 28110(Crenshaw Loche, Lot 4) ft ftT 1 t h—'t 1
Physical Address,City,and Zip 21.REMARKS - - - • --- - ' .. L=o- —.. -
Union 08153016 - NOV County Parcel Identification No.(PIN) f vJ ?
5b.Latitude and Longitude in degretx/miautes/seconds or decimal degrees: ln ;; =;
P•', ;:,,i'-''+t.:..t
dwell field,one lat/lon is sufficient 22.Certification: J .G
N W D L 9� Yr.61-36-V 3
Signature of Cirtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
. with I5A NCAC 02C.0100 or 1SA 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 d21 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: 185 (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(4)100) construction to the following: 1
10.Static water level below top of casing: 30 (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 - (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 Marl Service I Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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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