GW1--02768_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY: I '
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name �. 131 ft• 133 ft• I j 5 gpm
I •,.f r*1 1,cam-,f;
4070-A t -- L,.::i •`i/ k---i=; t) 135 ft• 140 ft. I 3 gpm
NC Well Contractor Certification Number r 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
MAY C. 7 2024 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 56 ft• 6 1/8 I, in. SDR-21 PVC
Company Name k17icri""s'i1 ' .,.- '`: +UFA 16.INNER CASING OR TUBING(geothermal closed-loop)
;`v` .12.k Cif FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 24-30 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 OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑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)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
ft. ft. •
[Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 g ft. Brown Dirt
3/22/24 19 fr. 36 ft• Brown Rock
4.Date Well(s)Completed: Well ID#
36 ft. 245 ft. Slate
5a.Well Location: ft. ft.
Ronnie Love
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Seams:71',76',89', 102', 131'=5gpm,
Old Fer Rd, Monroe 28110 ft. ft. 135'=3g,214'
ry ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 08060010D
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) �{/+
U I N W PG L r` 4/15/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifyjthat the 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 ONo 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
1
9.Total well depth below land surface: 245 (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:
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 ServiceiCcnter,Raleigh,NC 27699-1617
i' '
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: j
(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 m 8 Method of test: Air 24c.For Water Supply&Injection Wells:
lgl? ) 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