GW1-2022-10030_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
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14.WATER ZONES '
Dwight L. Huneycutt FROM To I DESCRHMON i
Well Contractor Name E
510 It- 520 ft' I 18 gpm
4070-A i� 5 v n-U ft. ft. i
NC Well Contractor Certification Number O,V 0I �O�� 15.OUTER CASING for multi-eased wells OR LINER if a licable
7 FROM TO DIAMETER 'THICIINFSS MATERIAL
Derry's Well Drilling, Inc. 0 53 ft 61/8 SDR-21 PVC
Company Name iR(ivPe '�'� i " r✓, .`� 16,INNER CASING OR TUBING(geothermal closed-loo
22-198 Dv.1Q130G FROM TO DIAMETER 'THICKNE S MATERIAL
2.Well Construction Permit#: ft. ft. in
LisI all applicable well permits f.e.County,State,Variance,Injection,elc.) ft ft. is
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO mAMETER SLOT SIZE THICKNESS MATERAL
ft. ft. in.
❑Agricultural ❑MunicipaliPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f ft is❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
ElIrrigation 0 ft' 3 ft. Bent.Chips, Gravity
Non-Water Supply Well:
3 ft 20 fc Bentonite Pumped
❑Monitoring ❑Recovery
Injection well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if applicable)
;
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tour,hardness,softock srze,etc
0Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 IL 6 ft. Wet Brown Dirt
Brown Dirt
4.Date Well(s)Completed: 7/21/22 Well EN 13
ft. 13 ft.
13 fL 23 ft. Brown Rock
5a.Well Location: 23 It- 600 ft. Slate
Metrolina Christian Academy FL &
Facility/Owner Name Facility ID#(if applicable)
Rosemary Park, Lot 8,Wampum Dr., Indian Trail 28019 ft ft Seams:95', 136',218',492',510'=18gpm
ft. tY.
Physical Address,City,and Zip
21.REMARKS
Union 07084160
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)
N W �lifltL ,C_. L[yl�2t/f — 8/11/22
Signature of CcMfled Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certo that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
If this is a repair,fell out known well construction information and explain the nature of the
repair under#21 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 form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 600 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2@1001 construction to the following:
10.Static water level below top of casing: 31 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above 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
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 276994636
13a.Yield(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
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed. 11
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013