GW1--01916_Well Construction - GW1_20240325

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—.----,7-"":I. i cr.-•7-yt FROM
14.WATER ZONES TO DESCRIPTION: _.
Well Contractor Name .CL.-- _"L r" V -.-,Lr7 171 ft 179 ft- I 2 gpm
4070-A MAR 2 :� 2024 ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. lnftwi.:rrs"''•'')'-:-.-- 4''' U:: o k 44 ft 61/8 SDR-21 PVC
Company Name ., 16.INNER CASING OR TUBING(geothermal closed-loop)
23-100 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft ,•
in
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
H. H. in.
DAgricultural ❑Municipal/Public ,
ft❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) is.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)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier ft. ft. -
❑Aquifer Test ❑Stormwater Drainage
ft- ft.
❑Experimental Technology ❑Subsidence Control , 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 19 ft. Brown Dirt
9/14/23 19 f 500 ft 1' Blue Rock
4,Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft ft.
Aaron Reed ft ft. 'Seams: 133', 171'=2g
Facility/Owner Name Facility ID#(if applicable)
ft. ft
3711 Sikes Mill Rd, Monroe 28110 ft ft
Physical Address,City,and Zip 21.REMARKS
Union 08-126-016G
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `i, iti.e., /te-.L. i 9/30/23
Signature of Certified Well Contractor i Date
6.Is(are)the weIl(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 ENo 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: 500 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well ,
For multiple wells list all depths ifd fferent(example-3@200'and 2@100') construction to the following: i
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 Infection 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
(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) 2 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form iwithin 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