GW1-2021-00826_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: i
Dwight L. Huneycutt 14.FR WATER ZOOMDESCRIPTION
Well Contractor Name 115 rL 125 ft. 15 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
FROM TO DIAMETER THICKNESS MA1'ERUIL
Derry's Well Drilling, Inc. 0 it. 154 ft s 1/8 SDR-21 PVC
Company Name l6.INNER CASING OR TUBING(geothermal closed-loo
21-253 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,lnjechom etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic R. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. h• in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) M GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft 85 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
Ill. it
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnn soil/rock in sir.,da
❑Geothermal (Heating/Cooling Return ❑Other(explain under 421 Remarks) 0 ft. 12 ft. Red Dirt
4,Date Wells)Completed: 9/25/21 Well ID# 12 ft. 32 ft. Brown Dirt
32 ft. 185 1` Slate
5a.Well Location: ft. ft.
Lisa Rawson fL ft.
Facility/Owner Name Facility mk(if applicable) fL ft- Seams:72-75',79;88',,115'=15g
4822 Little Sleepy Hollow Rd, Marshville 28103 ft rt
Physical Address,City,and Zip 21.REMARKS
Union 03-018-023 202
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one[at/long is sufficient)
N W 10/20/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
!3v signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ElNo copy ofthis record has been provided to thelrvell 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a(3200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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.c.auger,rotary,cable,direct push,etc.) I.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gP ) 15 Method of test: Air 24c.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 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