GW1-2022-04351_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FR WATER ZONES ;
FROM TO DESCRIPTION
Well Contractor Name 215 f` 220 ft 15 gpm
4070-A ft. ft
j�;^1p,
{ 15.OUTER CASING for multi cased welts OR LINER if a licahle
NC Well Contractor Certification Number t ;�,u,.L
�,,�,• i if'`;.'.��`'� FROM TO DIAMETER THIl'�]FSS MATERIAL
Derry's Well Drilling, Inc. ''''` ' " ' 0 ft. 75 ft- 61/8 In 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermel dosed-loop)
10012355 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft ft
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. to
❑industrial/Commercial ❑Residential Water Supply(shared) /9.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundeweter Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Ct. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets itoecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bananas soill ck type,grain sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft Red Clay
7/28/21 25 ft 52 ft. Brown Dirt
4.Date Wells}Completed: Well iD#
52 ft 66 ft. Brown Granite
Sa.Well Location: 66 ft• 300 ft Blue Granite
Raymond Morgan ft. ft
Facility/Owner Name Facility 1D#(if applicable) rt. ft
1 Seams:79',s21,ss, 13s�, 1sa�, 181�,
2201 Ranburne Rd, Charlotte 28227
rt. rt. 215'=159
Physical Address,City,and Zip 21 REMARKS
Mecklenburg 197-031-37
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) /
N W L�,L GU 3/25/21
Signature of.ertitied Well Contractor Date
6.Is(are)the well(s): 171'ermanent or ❑Temporary By signing this form,1 hereby certify than the well(s)was 6vere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: ❑Yes or ❑No 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 r21 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
&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 eonsbuction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
har multiple wells list all depths ifd Brent(example-3(200'and 2«100') construction to the following:
10.Static water level below top of casing- 42 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is abm,e casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 pusk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
15 Air 24c.For Water Supply&Injection i W ells:
13a.]'field(gam) Method of test: 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 R I ounces Revised August 2013