GW1-2021-04597_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For intern►Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Dwight L. Huneycutt IF4R.WATER2TO�S DESCRIPTION
Well Contractor Name 448 ft. 455 ft. 50 gpm
4070-A �
NC Well Contractor Certification Number v 15.OUTER CASING for multi cased wells OR LINER If ap q
lcable
Derry's Well Drilling, Inc. PQ� �o�eso 0�•� n as n 6 1 8 ltn SDR 21 I °�'TERP C
Company Name IV" 16.INNER CASING OR TUBING(geothermal closed-loop)
10011174 a� , 9� FROM n TO n. DLAMETERI ln. TffiCKNESS MATERIAL
2.Well Construction Permit#: `�
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) n. n in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
n. n.❑Agricultural ❑MunicipaMblic in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n n• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUN r
OIrrigatiNon-War r Supply Well: 0 n• 3 n Bent.Chips Gravity
❑Monitoring ❑Recov 3 n' 35 n Bentonitt Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
FROM TO MATERIAL IF11tPI.ACFAIENfMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
❑Geothermal eating/Cooling Return ❑other(explain under#21 Remarks 0 n 10 n Fill Dirt
$/24/20 10 n 25 n Red Clay
4.Date Well(s)Completed: Well ID# 25 n. 70 n. Wet Brown Clay
5a.Well Location:
L�. 70 n 82 n Brown Granite
far weft vLin 5 L 82 n 465 n Blue Granite
Facility/Owner Name Facility ID#(if applicable)
OldS-ECAdes V,11e, �., Ch(A n. n. Seams: 115',23�0'$3��'9357',435',442',
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 037-211-09
Comity Parcel identification No.(PIN)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer dlieation:
(if well field,one lattlong is sufficient)
Pwe � ' 9/15/20
N W
Signature of Certified Well Contractor Dare
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Constriction 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#11 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY utith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 465 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: j
10.Static water level below top of casing: 13 (}q,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: hi 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: ry 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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form iwithin 30 days of completion of
136.Dlslnfectlon type: Amount: 1/2 I b.
Granular well construction to the county health department of the county where
constructed. I!I
Fonu OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013