GW1-2022-04277_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt F4.WATER ZONES FROM TO I DESCRIPTION
Well Contractor Name T —� 455 ft- 465 ft• 12 gpm
4070-A fL ft.
NC Well Contractor Certification Number AP D f► $ 15.OUTER CASING for multi-cased wells OR LINER if applicable.)
FROM TO DIAMETER THICIQ(ESS MATERIAL
Derry's Well Drilling, Inc. o ft 55 fL s vs in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
21-347 FROM I TO I DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: t: . v '�'� ft. ft. in
List all applicable well permits(i.e.County,Sta e,'Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f6 ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑bri ation Q It. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 35 ft Bentonite Pumped
Injection Well: ft. ft.
❑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
fL 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,grain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 it- 21 ft. Brown Dirt
11/12/21 21 fit- 29 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
29 1' 525 It- Slate
5a.Well Location: ft. ft.
Jeffery C. Brown fL It.
Facility/Owner Name Facitity ID#(if applicable) fL
fL Seams: 59',96', 134,250,269',
2522 Ansonville Rd., Marshville 28103
rL ft. 455'=12g
Physical Address,City,and Zip 21 REMARKS
Union 02167003A
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) • /
Signature ofrertified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
Ifthis 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 ONLYwith the some construction,you can
submit one form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 525 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 41 (ft,) 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 (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.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) 12 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forml within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county heaith department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013