GW1-2022-04287_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Dwight L. Huneycutt FRO WAT TO I ER - DESCRIPTION
Well Contractor Name 172 ft 178 ft 7 gpm
4070-A
NC Well Contractor Certificat on Number 15.OUTER CASING for multi-cased wells"OR L[NER it a livable
FROM TO DIAMETER TMCICIYESS NfATERiAI.
Derry's Well Drilling, Inc. 0 fl 46 ft 6 1/8 '" SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-315 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: h• R• in.
List all applicable hell permits(i.e.Coumy.State,Variance.Injection,etc.j
ft. ft. i
e n.
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) RlResidential Water Supply(single) ft. R. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM '10 MATERIALS EMPLACEMENTME'1'HOD&AMOUNT
❑Trri ation 0 ft. 3 tt Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 35 fL Bentonite Pumped
❑Monitoring ❑Recovery
ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACENffNT A=OD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
it. 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.wain sae etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fL 11 ft' Red Clay
12/15/21 11 ft• 19 ff. Brown Rock
4.Date Well(s)Completed: Well TD# � �
19 245 Slate
59.Well Location: ft. ft.
Manuel Jimenez ft. ft.
Facility/Owner Name Facility ID4(if applicable) fL ft
2805 Lucy Shortcut Rd., Marshville 28103 fL Seams:52',55', 115', 172'=7g
Physical Address,City,and 7ip 21•REMARKS — ! {
Union 02-133-027H
County Parcel identification No.(PIN) APR 0 112022
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one fat/long is sufficient)
L. .GlC 12/28/21
.,,
N W �„ ,,,,.'Tl(
Signature o ertified Well Contractor Dbf�.
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifj,that the irell(s)was(irere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC UPC.0200 Well Consiruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the hell owner.
If this is a repair,fill out known well construction infornwtion and explain the nature of the _
repair tinder'E21 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
h'or nudtiple ityection or non-wafer supply wells ONLY with the same construction,you can
SUBMITTAL INSTUCTTOVS
suhind one form_
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of welt
For anduple trells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.)
38 Division of Water Resources,information Processing Unit,
ffwater level is above casing,rise••-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Injection 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 m 7 Method of test: Air 24c.For Water Supply&Injection Wells:
(gP ) 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.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013