GW1-2021-00007_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 135 fL 140 IL 100 gpm
4070-A fr.
NC Well Contractor Certification Number IS.OUTER CASING for multi cased wells O LINER if a litable
FROM TO DIAMETER R TffiCKNESS AiATEWAL
Derry's Well Drilling, Inc. 0 ft 44 fit- 6 118 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. :in.
List all applicable well permits ii.e.County,Suite,Variance,Injection,etc.)
ft. @. an.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
& ft. in.
❑O Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 fr. 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr. TO @. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
f4 CL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheet it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardFms,soil/o k tyM grain s12e,eta
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) 0 ft 11 ft Brown-DirtRoek
4.Date Well(s)Completed: 10/5/21 Well iIM 11 ft- 145 ft- y Slate
ft ft.
5a.Well Location: ft. ft. 202 1
David Ward It. AL
Facility!OwnerName Facility tD#(if applicable) It. IL Seams:'58 12',405 109=113 .135'=100g
730 Bethel Church Rd., Mt. Pleasant 28124 & fr
Physical Address,City.and Zip 21•REMARKS
Cabarrus
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one latflong is sufficient)
N W
Gitt� � "'uLR'w 11/8/21
Signature of .ertitied Well Contractor Date
6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing this form, I hereby certify that the well(v)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A N(AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or E]No copy of this record has been provided to the well owner.
If this is a repair,fill ono known well construction information and explain the nature of the
repair under i21 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 wells ONLY with the same construction,you can
submit one form SUBMITTAL iNSTIJMONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfderent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,information Processing Unit,
ifwater level is above casing,use••+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 (in.) 24b.For iniection Wells ONLY: i6 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 construction to the following: i
(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) 100 Method of test: Air
24c,For Water Supply&Injection Wells:
Also submit one copy of this form jwithin 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
I
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013