GW1-2021-05879_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
_ FROM TO DESCRIPTION
Well Contractor Name © (� 20 205 ft- 210 fb 7 gpm
4070-A I't, ft. !
NC Well Contractor Certification Number pCCvQ�g��g i5 OUTER CASING for multi cased wrens OR LINER if a livable
TERIAL
Derry's Well Drilling, Inc. �c��o��"3p� �S��,on 0 oM f1. ft- 16118 Rrn S�1 PLPVC
Company Name 16.INNER CASING OR TUBING(geothermal close&loo
20-48 FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#. ft. for. in
List all applicable well permits lie.County,State,Variance,injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. hL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
❑TITi ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 35 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To nfATERIAI. EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. [L
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soit'roek rain size,etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft- 21 ft Brown Dirt
4/20/21 21 fL 265 fL Slate
4.Date Well(s)Completed: Well ill# ft. ft.
sa.Well Location: ft. ft.
Will Auret ft. ft.
Facility/Owner Name Facility 1D#(if applicable)
ft. ft. . Seams:77', 111',205'=7g
6322 Olive Branch Rd., Marshville 28103 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 02199002
County Parcel identification No.(PTN)
5b.Latitude and Longitude in degreesfminutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one fat/long is sufficient)
N W ' " 5/10/21
Signature Well Contractor V Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 hereby certify that the well(y)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 [KIND 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form SUIIMiTTAL iNSTiTMONS
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9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdti ferent(example-3 200'and 2 rr 100) construction to the following:
10.Static water level below top of casing: 41 00 Division of Water Resources,information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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I I.Borehole diameter: 6 24b.For Infection Wells ONLY: JTn}addition to sending the form to the address in
Rotary 24aabove, 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.) i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method oftest: 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 lbo well construction to the county health department of the county where
constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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