GW1--02779_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:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION I
Well Contractor Name 50 ft• 57 it 1 , 5 gpm
'�F.P y •�, ft ft
2465-A ������� ,, -i �� 225 230 ;. � 95 gpm
r <h"k '^.t j 11,�,(i ) 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAY u i 2024 0 tt• 45 ft 61/8 PL SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
P Y IPr Jr:r.:,a\"it:'1S--,^..Ks;;,a' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 23-133 n'tU t.,•_,J y ')' ft. ft. +i
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
DAgricultural ❑Municipal/Public H. It. in 1
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) ft ft. 'n
❑Industrial/Commercial ❑Residential Water Supply(shared) IS'GROUT
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑lrrigation 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 ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. i
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 3 ft ; Brown Dirt
4.Date Well(s)Completed: 3/4/24 Well ID# 3 f 230 It Slate
ft. ft.
5a.Well Location: ft. ft.
Robert Dulin
Facility/Owner Name Facility IDk(if applicable) Seams:50-57'=5g, 110', 130', 135',
ft ft 230'=95g
7604 Tesh Rd., Monroe 28110
ft. ft
Physical Address,City,and Zip 21.REMARKS
Union 08156001C
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) // '�,� l) ,,(�
N Rr Cr1 (mot/. r f 3/28/24
Sign a of Certified Well Contractor I Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certiO that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis'record has been provided to theiwell owner.
If this is a repair,fill out known well construction information and explain the nature of the i
repair under 421 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 I
submit one form. SUBMITTAL INSTUCTIONS i,
9.Total well depth below land surface: 230 (tt•) 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:
I.
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: hi addition to sending the form to the address in
Rotary24a 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,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce ter,Raleigh,NC 27699-1636
100 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 Ib. well construction to the county health department of the county where
constructed.
1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
,