GW1-2022-10048_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multi pie wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES 6
FROM TO DESCRIPTIONI
Well Contractor Name U ­ +iL,i t"' 101 ft- 110 ft. I j 35 9Pm
4070-A ft. ft.
NC Well Contractor Certification Number NOV Y V 7 2022 15.OUTER CASING for multi-rased wells OR LINER if applicable)
FROM TO DIAMETER. THICKNESS MATERIAL
Derry's Well Drilling, Inc. lrli^sri i'r� ,s;;nr unii 0 ft- 46 ft- 61/8 iin. I SDR-21 I PVC
Company Name + Li OG 16.INNER CASING OR TUBING(geothermal dosed-loop)
22-79 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fa I 1;in.
List all applicable well permits(i.e.County,State,Yariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I,SLOT SIZE THICKNESS MATERIAL
ft. ft. in. I
❑Agricultural ❑Municipal/Public I
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. �•
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 f4 Bent.Chips Gravity
Non-Water Supply'Well:
[]Monitoring ❑Recovery 3 B 20 fL Bentonite Pumped
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. i,
❑Aquifer Test ❑Stormwater Drainage it
ft. ft. i
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION color,hardness soil/rock ain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. I; Red Dirt
4.Date Well(s)Completed: 5/16/22 ' Well ID# 5 fL 19 ft. j Brown Rock
19 ft- 165 ft• Slate
5a.Well Location: fL ft.
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Jeffrey Brown ft. ft.
Facility/Owner Name Facility ID4(if applicable) 1,
ft. ft' Seams: 58•,69',78',91-96',101'=35g
2526 Ansonville Rd., Marshville 28103
ft. re.
Physical Address,City,and Zip 21.REMARKS
Union 02-167-003H
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 6/4/22
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this form,I hereby certify that Ithe rvell(s),vas(were)constructed it:accordance
with 154 NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the.well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe I ,
repair under tl21 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 INSTUCTIONS I
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9.Total well depth below land surface: 165 (ft-) 24a. For All Wells: Submit this fortn within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3ta3200'and 2®100� construction to the following:
10.Static water level below top of casing: 12 (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 Iniection Wells ONLY: It addition to Sending the form to the address in
24a above, also submit a copy of this iforn 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
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13a.Yield m 35 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 hcaith department of the county where
constructed. I I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Reso Ices Revised August 2013
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