GW1--01901_Well Construction - GW1_20240325

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES. ';
Y FROM TO DESCRIPTION I
Well Contractor Name 468 ft: 470 R• 1 I 10 gpm
2465-A :_,F. :L L:is .'vs' Nz L.. ft. .ft. , i
NC Well Contractor Certification Number ^/ ? .15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) -
MAR 2 LOZ4 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 46 ft. 6 1/8 SDR-21 PVC
Company Name illiG Fi.:%s n? '...z.;..y.ng U 4 i 16.INNER CASING OR TUBING(Eeothermal closed-loopy :
�,,.,..�. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22-3 Gl it„'' ft. ft, ill-
List allapplicable 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 R. ft in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. - R. 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:
❑Monitoring ❑Recovery 3 ft• 20 ft• Bentonite , Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL,PACK(if applicable): - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
DAquifer Test ❑StormwaterDrainage ft ft.
' ❑Experimental Technology 0 Subsidence Control 1
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM , TO DESCRIPTION(color,hardness.soil/rock type,grain size,etel
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) t 0 ft• 10 ft. Brown Dirt
9/20/23 10 ft 480 ft• Blue Rock.
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: ft: ft.
Amanda Estelle ft• R. Seams:70',85',90', 110', 137', 170',
Facility/Owner Name Facility Ikl(if applicable) R. ft• 200';210',230-240',270',290',305',
2116 Purser Rushing Rd, Monroe 28110 R. R. 330',375',407',428',450',468-470'=10g
Physical Address,City,and Zip 21.REMARKS
Union .08099017L
County Parcel identification No.(PiN) t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: •
(if well field,one lat/long is sufficient) f ,, J
�B/LPL a . r 10/15/23
N W Si, re of Cettified Well Contractor ; Date
6.Is(are)the well(s): Permanent or OTemporary By signing this form,I hereby cerq/jj&lhati the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A/CAC'02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to ilk well owner
If this is a repair,fill out known well construction information and explain the nature of the
repair under i2I 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 i
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 480 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of'well
For multiple welts list all depths if different(example-3@200'and 2 4C)100') construction to the following:
10.Static water level below top of casing: 30, - (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Cef ter,Raleigh,NC 27699-1617
II.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: 1(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) 1 Method of test:0Air 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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