GW1-2022-10060_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used forsingle or multiple wells
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1.Well Contractor Information:
John W. Huneycutt I4.WATER ZONES`
FROM TO DESCRIPTION i
Well Contractor Name q P, ye gy" i 355 tt• 362 tt 2 gpm
2465-A r:- �s 5�� d� `� ` tr ft.
NC Well Contractor Certification Number N O V ,J 2022 '15.OUTEWCASING for multi-cased-wells!!OR a l LINER if icable
FROM TO DLAMETER i THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 46 ft- 61/8 io.: SDR-21 PVC
Company Name Irlit.r'rRuw a p °16.INNER CASING OR TUBING(geothermal closed-]Go
21-333 FROM TO DIAMETER P 1 THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.;
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List all applicable well permits(1.e.County,Slate,Variance,Injection,etc.)
& ft in.
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 51ATERiAr
❑Agricultural ❑MunicipaUPublic ft. ft. in-
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 ft' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3` ft 20 ft Bentonite' Pumped
❑Monitoring ❑Recovery
Injection Well: ft f<
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL`PACK(if a licable)
..❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL i EMPLACEMENT DIETHOD ft. i
❑Aquifer Test ❑Stoimwater Drainage
ft, ft. I
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sefllrocktypc size,etc)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks), 0 ft. 9 ft. ; Brown Dirt
3/14/22 9 ft. 29 ft Brown Rock
4.Date Well(s)Completed: Well 1D# 29 ft 465 ft.
Blue Rock
5a.Well Location: ft, ft.
DC Homes.
fw fLSeams: ;60',75',80', 120', 190',203',215'
Facility/Owner Name Facility ID#(if applicable)
fr. 'ft. 230',2,40';250',255',267',285',297',
6222 Olive Branch Rd., Marshville 28103 ft. ft. ,
333,'355=29,367,375,395',415
Physical Address,City,and Zip 21.REMARKS '
Union 02-199-002B
County Parcel Identification No.(PIN) I.
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5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is,sufficient)
N R, w•r 4/6/22
Sign0ke of Certified Well Contractor Date
6,Is(are)the well(s): ©Permanent or ❑Temporary.
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or, ENO copy of this record has been provided to the ii ell 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.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
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 INSTUCTIONS
9.Total Well depth below land surface: 465 (ft) 24a. For All Wells: Submit this fo Arm within 30,days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
lll•Static water level below top of casing:
35 (ft.) Division of Water Resources,Information Processing Unit,
If water 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 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(ie.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 2 Method of test: Air I
Also submit one copy of this form whinit 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. - well construction to the county healthy apartment of the county where
constructed.
Form GW-1 North Carolina Department ofEnvuonment and Natural Resources—Division of Water Resent s Revised August 2013
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