GW1--01906_Well Construction - GW1_20240325

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1
WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Dwight L. Huneycutt ' '7- . ,'- ' 14.WATER ZONES ' .1 I -
\ +;:„. ? FROM TO DESCRIPTION
Well Contractor Name d ""`'a. a Y: 7.a# 133 ft• 136 ft. 1 ' 2 gpm
4070-A MAR 2 e-' 20Z4 150 ft. 160 ft. 1, ' 16 gpm
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
,.-,•��,_��...t,: i� FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, In�TMi3','TM~{44F,,rM a, .4 �`° ft ft , in
t l 0 54 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-210 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): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) giResidential Water Supply(single) ft ft. is
❑lndustrial/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 OSalinity 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)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrocle type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 13 ft. Red Dirt
4.Date Well(s)Completed: 9/28/23 Well Mg 13 ft 33 ft Brown Dirt
33 It 46 ft Brown Rock
5a.Well Location:
46 ft 225 f` i Slate
Mark Penegar '-
2g,
Facility/Owner Name Facility ID#(if applicable) Seams:59',66', 115', 133-
ft • ft 150'=16g
Ellis Griffin Rd., Monroe 28110 `
ft. ft '
Physical Address,City,and Zip 21.REMARKS
Union 02-236-006E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(dwell field,one lat/long is sufficient)
N W L. r, l•,7c../...ett- 10/14/23
Signature of ' ed Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,1 hereby certi&that die well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 1 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 Ail 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 easing: 30 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
! I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i e.auger,rotary,cable,direct push etc.) •
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Ralei h,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: ! g
18 Air 24c.For Water Supply&Injection Wells: •
13a.Yield(gpm) Method of test: •
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