GW1-2021-00837_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD I or mlernal Use oNLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 115 ft' 120 fL 7 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased a ells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 144 ft 6 1/8 i" SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING e6thermal closed-loop)
21-72 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stare,I'ariance,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) EiResidential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑tuff ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f`' 35 Bentonite Pumped
ft'
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
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 18 ft. Brown Dirt
7/20/21 18 ft- 31 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
31 ft• 205 ft. Blue Rock
5a.Well Location:
Brian Benton ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. it.
7342 Pleasant Hill Church Rd., Marshville 28103 seams: 115=7g, 118, 1so
l,,�,� rt. rt.
Physical Address,City,and Zip 161 ` 21.REMARKS
Union 01084012N k
County Parcel Identification No.(PIN) ae
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient) i
tutu
Sigmi§4c of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)ryas(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy of this record has been provided to the well 01171er.
If this is a repair,fill out krroirn well construction irrfrlrmation and captain the nature of the
repair corder 421 remarks section ar on the back of this forni. 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 constriction details. You may also attach additional pages if necessary.
For multiple injection or non-water snpp(v it-ells ONLY with the sane construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 42 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b. For Infection Wells ONLY: jln 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
13a.Yield(gpm) 7 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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