GW1-2022-04352_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information: 14.
_
Dwight L. Huneycutt FROMATER2ANES TO DESCRIPTION
Well Contractor Name APD 189 fr' 195 fit• j 3gpm
4070-A 1� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi tasedwells OR LINER if a licable
• _ �', '." FROM TO DIAMETER THICKNESS MATERUL
Derry's Well Drilling, Inc. , 4 :J;,-. '7 0 fit. 70 ft- 61/8 "- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal elosed-loo
10012476 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: ft. ft. I.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. rn
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 fL 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
EMPLA
❑Aquifer Storage and Recovery ❑Salinity FROM TO Barrier ft. tr. MATERIAL CEMENTDIETHOD
❑Aquifer Test ❑Storm water Drainage
[t. tL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.sciVrock CyM gritim shv,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fit- 12 ft Orange Dirt
4.Date Well(s)Completed: 9/16/21 Well iIM 12 ft 45 ft Brown Dirt
45 fL 61 ft. Brown Granite
5a.Well Location:
Lonnie K Greene 61 ft. 305 ft. Blue Granite
ft. ft.
Facility/Owner Name Facility iD4(if applicable)
rt. rL Seams:90',97', 134', 189'=3g
9601 Ferguson Rd, Charlotte 28107
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 197-031-37
County Parcel identification No.(PtN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one[at/long is sufficient) /
N W _ ��.C�. � 3/25/21
Signature of ertitied Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary py,sig tins this form,1 hereby certify that the we(/(+)was(were)constructed in accordance
with I5A N(.AC 02C.0/00 or 15A NCAC 02C.0200 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to the.well ou-ner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under h21 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
S.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 form- SUBMITTAL INSTIICTiONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing- 43 (ft.) Division of Water Resources,information Processing Unit,
Ifwater 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
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 27699-1636
13a.Yield(gpm) 3 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 Ib. well construction to the county healih department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013