GW1--02733_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FAR.OMATERZONES TO DESCRIPTION
Well Contractor Name -.� r , ,.r 211 ft 215 ft I 1 2 gpm
4070-A 1.'�.,..R s:.i,k%{R:,1) 295 ft• 300 ft• I i2 gpm
L r�.� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number
MAY d e U FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft• 6 1/8 1 'in• SDR-21 PVC
Company Name lflt:'vs.%i.,1."''`',0*"; "`vU 16.INNER CASING OR TUBING(geothermal closed-loop)
24-52 EY1.c�;'3'.wr 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
• ft. ft. in.
❑Agricultural ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) ilResidential Water Supply(single) ft. ft. 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 ❑Rewvery 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.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 17 ft. Brown Dirt
4/3/24 17 it 29 ft. Brown Rock
4.Date Well(s)Completed: Well DO ,
29 ft• 325 ft• Slate
5a.Well Location: ft. ft.
Michael D. Walden ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. Seams:57',73, 105, 119, 148, 155, 196
. 2822 Old Pageland Monroe Rd, Monroe 28110 ft. ft. . 211'=2g,289',295'=2g
Physical Address,City,and Zip 21.REMARKS
Union 04-006-001 A
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 W . pi/ezfrtre&-'
4/12/24
Signature of Certified Well Contractor ; Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 5A NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E No 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 i,
9.Total well depth below land surface: 325 (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@100')' construction to the following:
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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 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: $ '
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 4 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. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water1R I ources Revised August 2013