GW1--02732_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt F FROM TO DESCRIPTION;
Well Contractor Name T^r•, r. c 77 ft 81 ft I I 5 gpm
.r' ,e a i,_,i •
4070-A 't ..�. -i.,.i 11-e./ 84 ft 89 ft. I ! 3 gpm
NC Well Contractor Certification Number r n . 15.OUTER CASING:(for multi-cased wells)OR LINER(if ap licable)
MAY i, cu24 FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 63 ft 61/8 SDR-21 PVC
Company Name trifOr i'-r:A<'r2 ''.'' `•":,1474 LIKaft 16.INNER CASING OR TUBING(geothermal closed-loop)
23-255 Cirri Cict+f:il.3 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 Iise): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. ❑Agricultural ❑Municipal/Public ft m
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation o ft. 3 f- 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
rt. ft. i
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TIacer FROM TO DESCRIPTION(color,hardness,soiliroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 ft Red Dirt
3/19/24 6 ft. 22 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
22 it 29 ft Brown Rock
5a.Well Location:
Thomas& Lori Coppedge 29 fr 55 ft i Junky Slate
55 300 Slate
Facility/Owner Name Facility ID#(if applicable)
5318 Su gar&Wine Rd., Monroe 28110 ft aSeams:77-81'=5g,84-89'=3g,97', 105',
g ft. ft. 138'
Physical Address,City,and Zip 21.REMARKS '
Union 01-201-025D
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
N W �Gti� 1--- ri71.1417att- 4/15/24
Signature of ed Well Contractor i Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certity 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 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#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 die same construction,you can
• submit one form. SUBMITTAL INSTUCTIONS I
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 ifdifferent(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 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: f I
(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
24c.For Water Supply&Injection Wells 13a.Yield(gpm) 8 Method of test: Air
ls:
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