GW1-2021-04516_Well Construction - GW1_20210429

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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:
DWI ht L. Huneycutt a, 14.WATER ZONES
9 Y q FROM TO DESCRIPTION i
Well Contractor Name 148 ft- 155 ft' I 50 gpm
4070-A R R 2 9 2021 it. ft.
NC Well Contractor Certification Number V 15.OUTER CASING for multi-cased wells OR LINER if a licable
' ,��ggS1n� FROM TO DIAMETER! THICKNESS MATERIAL
Derry's Well Drilling, Inc. ate Pcg, ;on o ft so ft 6 1/8 SDR-21 PVC
Company Name UNIti t`v 16.INNER CASING OR TUBING(geothermal dosed400
20-494 FROM TO DIAMETER! THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
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 ISLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) l7lResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑ F
Residential Water Supply(shared) GROUT
FROM TO MATERL4Li EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 35 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
❑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.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hsrdness soil/rock type, in size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It. 16 ft. Brown Dirt
1/19/21 16 rt' 21 ft• Brown Rock
4.Date Well(s)Completed: Well ID#
21 ft. 165 It. Slate
5a.Well Location:
Rick Ammons
Facility/Owner Name Facility ID#(if applicable) ft ft. Seams:63',70',75', 129', 133', 137',
4727 Calvert Ct., Marshville 28103 (Calvert PI Lt4) ft. tt.
148-155'=50g
Physical Address,City,and Zip 2L REMARKS
Union 01177007D
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)
N W 2/10/21
Signature ofillertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9lNo copy of this record has been provided to the'ryell 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(exomple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 16 (ft-) Division of Water Resources,Information Processing Unit,
If}vater level is above casing,ruse"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In;addition to sending the form to the address in
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) 50 Method of test: Air 4c.For Water Supply&Injection Wells
2 :
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 department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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