GW1-2022-04286_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:
ROM F
Dwight L. Huneycutt ER ZONES
FROM TO DESCRIPTION
Well cnatrndar Name 150 ft 160 ft 15 gpm
J
4070-A QQ ft ft
NC Well Contractor Certification Number APR 0 J 2W 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 49 ft- 6 1/8 '" SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermnl closed-too
21-374:, ^;
RROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#. �� •' ft. fr. 1q•
List all applicable well permits(i.e.County,Slate,parlance,Injection,etc.)
[t. ft. 1ri.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In•
❑Geothermal(Heating/Cooting Supply) EIResidential Water Supply(single) ft ft is
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fL
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if rm
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfroek type,grain sore,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 13 ft Brown Dirt
11/11/21 13 fL 22 ft. Brown Rock
4.Date Wells)Completed: Well il)d# 22 ft 185 f` Slate
5a.Well Location: ft. ft.
Lucas Croasmun ft ft
Facility/Owner Name Facility iD#(if applicable)
ft ft Seams:55',69% 130'136', 150'=15g
6003 Ansonville Rd., Marshville 28103 ft ft
Physical Address,City,and Zip 21 REMARKS
Union 01042018
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification-
(ifwell field,one latAong is sufficient) .L
N W � 11/25/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing this forna/hereby certify that the reel/(v)was(were)constructed in accordance
with 15A MAC 02C.0100 or ISA NCAC 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 out known well construction information and explain the nature of the
repair under r 21 remarks section or on the back of this farm. 23.Site diagram or additional weU 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-wafer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUC IONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
F'or multiple wells list all depths ifdierem(example-3@200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: 32 Division of Water Resources,information Processing Unit,
lfnaterhne/&above casing,use•'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: in 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.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 27699-16M
132.Yield(gpm) 15 Method oftest: 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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