GW1-2021-05857_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 RcJ V 14 FR.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 130 fL 140 ft 15 gpm
4070-A JUL 0 9 2021 ft
NC Well Contractor Certification Number ploceSSing Uni 15.OUTER CASING for mul/i-4med'wells OR R iNER if a licable
fG(rfi0ti0n FROM TO DIAMETER TTHl3�lESS DIATERI&L
In
Derry's Well Drilling, Inc. 0114 Seciion 0 ft 144 ft- 61/8 i° 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2020000061 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(1.e.County,State,Variance,Injection,etc.)
ft. ft. is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft im
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr' f to
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
[]Irrigation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 ft- Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
❑Aquifer Storage and Recovery []Salinity Barrier FROM ft.. To ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft !Z
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillroek tyM grain shm,Ne
❑Geothermal Heating/Coolin Return) ❑Other(explain under#21 Remarks) 0 fL 23 ft. Brown Dirt
ft ft-
Well Date Well 5/25/21 s)Completed: Well il)# 23 245 ft. ' Slate
ft.
5a.Well Location: ft. ft
Damien Liesman ft. ft.
Facility/Owner Name Facility 1D#(if applicable)
ft fL Seams: 55',65',75',92', 113', 119',
Boone Trail, Denton 27239 (Green Acres Park WC) it it 130'=15g
Physical Address,City,acid Zip 21.REMARKS
Davidson
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degreesfminutes/seconds or decimal degrees:
(if well field,.one fat/long is sufficient) 22 Certification:
N W D�� 6/22/21
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this forma 1 hereby certify that the wells)was(were)constructed in accordance
with iSA NCAC 02C.0I00 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑No copy(if 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 undere11 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.came construction,you can
submit eme form SITBMITTAL INSTITCriONS
9.Total well depth below land surface: 245 (ft.) 24a- For All Wells: Submit this,form within 30 days of completion of well
Nor multiple wells list all depths ifdiffereni(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 28 (ft.) Division of Water Resources,information Processing Unit,
ifnater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 01h) 24b.For Injection Wells ONLY: in 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,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
15 Method of test: Air 24e.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 ll) well construction to the county health department 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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