GW1-2022-10067_Well Construction - GW1_20221107

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells ;
1.Well Contractor Information:
Dwight L. Huneycutt FROM OM ER2 TOO.
...,+c� •{"' DESCRIPTION
Well Contractor Name .< eV, t 114 ft 120 ft I 60 gpm
4070-A ft n•
NC Well Contractor Certification Number
N Q V O 20�� 15.OUTER CASING for multi-cased well's OR LINER if a licable
FROM TO DIAMETER ! THICIiTiFSS �1 MATERIAL
Derry's Well Drilling, Inc. r. ,k;--)�` =.r.��"�i���� 0 ' ft' 65 ft 61/8 �is SDR-21 PVC
Company Name UN t"eq 16.INNER CASING OR TUBING(geothermal closed-loop)
22-001 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in
List all applicable well permits(1.e.County,State,Variance,Injection,etc.) ft. ft im
3.Well Use(check well use): 17.SCREEN
Water.Supply Well•_ FROM . TO DIAMETER SLOT SIZE THICIIIESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft ft in.
El Geothermal(Heating/Cooling Supply) hJResidential Water Supply(single) fL ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERAAr. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if metes
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnrss,sail/rock typc siMetc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft 8 ft i Red Dirt
4.Date Well(s)Completed: 4/1/22 Well ID# 8 ft. 25 ft Brown Dirt
25 ft. 53 ft Brown Rock
5a.Well Location: 53 ft 145 k j'' Slate
Justin Collins ft ft
Facility/Owner Name Facility ID#(if applicable)
f t seams: 70-73_88-s2',ss', 1os',
4822 Hwy 205, Marshville 28103
114-60gpm
Physical Address,City,and Zip 21.REDIARKS
Union 01-150-005A
County Parcel Identification No.(PIN)
5b.'Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification i
(ifwell field,one lat/iong is sufficient)
N W Z�ux;�l<t ,L-. 5/2/22
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify dial)lite well(s)was(were)constructed in accordance
with ISA 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 ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of file
repair under#21 remarks section or on the back of dds form. 23.Site diagram or additional well details:
J 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
j,
9.Total well depth below land surface: 145 00 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@100) construction to the following:
10.Static water level below top of casing: 10 00 Division of Water Resonices,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 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,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceneq t Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test: Air 24c.For Water Supply&Infection 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Reson!ees Revised August 2013