GW1-2022-04304_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 14.WATER ZONES F
g Y FROM TO DESCRIPTION
Well Contractor Name -•1 T:"`�� 150 ft- 155 f" 5 gpm
4070-A 267 ft• 275 f" f 13 gpm
NC Well Contractor Certification Number ��?7 15.OUTER CASING for multi cased wells'DR LINER if a livable
FROM 70 DIAMETER THiCI�iESS MATERIAL
Derry's Well Drilling, Inc. !^ 0 ft' 47 ft- 61/8 '" SDR-21 I PVC
Company Name ,�� � � ' �� 16.INNER CASING OR TUBING eothermaI closed-loop)
y V• L�Ji FROM TO DIAMETER! THICKNESS MATERIAL
21-346 ;
2.Well Construction Permit# t..
: to� 4,,1,k i, ft. ft. in
List all applicable well permits(i.e.County,Siate,!ariance,Injection,etc.)
fit. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 f"' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: fit. 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
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheefs it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardrims,soil/rock grain si2e,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. Brown Dirt
4.Date Wells)Completed: 12/7/21 Well iD# 6 ft- 16 ft Brown Rock
16 ft- 285 ft- Slate
5a.Well Location:
Summit Building Group fL ft.
Facility/(hvnerName Facility tD#(ifapplicable) fit. ft
Seams:65',72',90',95', 116', 150'=59,
6113 Bunn Simpson Rd., Marshville 28103 ft &
267'=13g
Physical Address,City,and Zip 21•REMARKS
Union 01-066-009H
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
W 1 i20/22
N if"
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hy signing this form,I hereby cernjp that the wells)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 END 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 ii21 remarks section or on the back ofthis,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 fotin SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths ifdiierent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 30 (ft,) 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 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.field(gpm) 18 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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