GW1-2021-05839_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: t0 0 f
Dwight L. Huneycutt � � F4.WATERZONES
PROM TO DESCRIPTION
Well Contractor Name O 9 20 128 ft 135 ft 90 gpm
4070-A �UL �� ft. ft.
NC Well Contractor Certification Number piQCeSg1119 15.OUTER CASING for multi cased wells OR LINER if a livable
tYl�dir"3t1Oi3�5gCV,011 FROM TO DIAMETER TffiCKNFSS MATERIAL
Derry's Well Drilling, Inc. t M J 0 ft- 154 ft-' 6 1/8 i0. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eolhermal dosed-loop)
21-212 FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: rt ft. in.
List all applicable well permits(i e.County,Slate,Variance,Injection,etc.)
R. [t. 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) ❑Residential Water Supply(single) ft. ft in
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 it 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
[t rt.[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if never
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardne,s,soilfroek type,grain size,etc.
❑Geothermal Heating/CoolingRetum) ❑Other(explain under#21 Remarks) 0 ft 22 ft Brown Dirt
4.Date Well(s)Completed: 6/10/21 Well iD# 22 ft 35 ft. Brown Rock
35 fr 145 ft. Slate
5a.Well Location: fr. ft
Jeffrey Smith Ft. ft
Facility/Owner Name Facility TD#(ifapplicable)
7927 Pleasant Hill Church Rd., Marshville 28103 ft ft. Seams:72�, 113, 119', 128'=90g
rt. It.
Physical Address,City.and Zip
21.REMARKS
Union 01081002E
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/smonds or decimal degrees: 22.Certification:(ifwell field one IaUlong is sufficient) � ��
N W
tit/ 6/30/21
Signature &6fied Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary Ry.signing this form,I hereby certify that 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 ❑No copy of this record has been provided to the well mrnfer.
Ifthis is a repair,full out known well construction information and explain the nature ofthe '
repair under ii21 remarks section or on the back ofthis 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. SUBMITTAL iNSTUCiTONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this'fort within 30 days of completion of well
Nor multiple wells list all depths if different(example-3(200'and 2ca 1001 construction to the following: ;
10.Static water level below top of casing: 12 (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 Tniection Welts ONLY: iq addition to sending the form to the address in
Rota 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.)
Division of Water Resources,lUnderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 90 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 depaitment of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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