GW1-2022-10057_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
1.Well Contractor Information:
14.WATER ZONES'.
Dwight L. Huneycutt FROM TO DESCRIPTION i
Well Contractor Name .3 c'—� �A'+ � a 64 ft. 70 f6 I ; 9Q grim
4070-A -' ft. ft.
NC Well Contractor Certification Number N O V O ? 20 2Z 15.OUTER CASING for multi-cased weds OR LINER if applicable)
FROM TO DIAMETER, F THICKNESS MATERIAL
Derry's Well Drilling, Inc. , gr„ �:�;,unil 0 f� 47 ft s 1/8 SDR-21 PVC
Company Name ' r�y��t'},f Qa j 16.INNER CASING OR TUBING eotherwat closed-loop)
21-70 FROM TO DIAMETER TIRCE NFSS MATERIAL
2.Well Construction Permit#: ft. fL 3u
List all applicable well permits(i.e.County,State,Variance,Injection,eta.)
ft. &
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIMIETER I SLOT SIZE THICKNESS MATERIAL.
ft ft in
❑Agriculttual pMunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft is !
❑htdustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL:' EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. '3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 fL 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK FROM TO if a licable-
❑Aquifer Storage and Recovery ❑Salinity Barrier k rt. MATERIAL EMPLACEMENT METH OD
❑Aquifer Test ❑Stormwater Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness sait/roclr ope,gr2in sire,etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft. Red Dirt
4/2/22 10 ft. 85 ft Blue Rock
4.Date Well(s)Completed: Well II)# ft. ft.
5a.Well Location: % ft.
Brian Benton/Emerald Pointe Realty fr. fr r
Facility/Owner Name Facility ID#(if applicable) f4
7324 Pleasant Hill Church Rd, Marshville 28103 Seams: 64'=9og
ft. ft. �
Physical Address,City,and Zip 21.REMARKS
Union 01084012P
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifweU field,one lat/long is sufficient) /
N W Zt� 5/2/22
Signature o Certified Well Contractor Date
6.Ls(are)the well(s): ©Permanent or ❑Temporary
13y signing this farm,I hereby certify that[he 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 ❑Nd 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#21 remarks section or on the back of dUs 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 85 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij dijjereru(example-3@200'and 2Q100) construction to the following:
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10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
Ijrvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 {inJ 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of[tits(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) 90 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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013