GW1-2021-04523_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: i
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION !
Well Contractor Name !�qp 313 r`' 320 r`' I 2 gpm
4070-Aa �
NC Well Contractor Certification Number q g 2p21 15.OUTER CASING for multi cased wells 'OR LINER f a livable
ppR 6d FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. _ ,,,gsc na U f" 148 ft• s 1/8 SDR-21 PVC
Company Name 1�tfD111;3it0nU' r C r{;Qri 16.INNER CASING OR TUBING(geothermal closed400
�'V sec FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20-144 ft. ft. in.
List all applicable well permils(i.e.Conntj,State,Variance,Injection,etc.) ft. ft. 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) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 IL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 r`' 35 r` 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 tt. ft.
❑Aquifer Test ❑Stormwater Drainage
rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,Wyin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 9 ft. iBrown Dirt
4.Date Well(s)Completed: 2/24/21 Well ID# 9 f`- 15 rt. Brown Rock
15 rt• 400 rt• Slate
5a.Well Location:
Walker&Judy Carpenter
Facility/Owner Name Facility ID#(if applicable)
rt. tt. Seams:55', 170',313'=2g
Carpenter Rd., Marshville 28103
Physical Address,City,and Zip 21.REMARKS
Union 01009002
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
N W r r 3/15/21
Signature ofterfified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
BY signing this form,1 hereby certifil that the weU(s)it-as(were)constructed in accordance
with 1 SA 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 0N0 copy oflhis record has been provided to the;well oyvmer.
If this is a repair,fill out biovm yell construction information and explain the nahtre of the
repair under 921 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.
For multiple injection or non-water supply vie/ls ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
40 Division of Water Resources,Information Processing Unit,
(ft.)
If,rater level is above casing,use"+" 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
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
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13a.Yield m 2 Method of test: Air 24c.For Water Supply&Injection Wells:
(Sp ) 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-I North Carolina Department of Environment and Natural Resources-Division of Water Relources Revised August 2013
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