GW1--07681_Well Construction - GW1_20231122

1
. I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
Dwight L. Huneycutt i 14.WATER ZONES i
FROM TO DESCRIPTION
'Well Contractor Name 213 f- 220 ft- I 6 gpm
4070-A ft.. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
•
FROM TO DIAMETER 1 THICKNESS MATERIAL '
Derry's Well Drilling, Inc. o f- 78' ft- 6 1/8 i SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-144 FROM • TO DIAMETER 1 THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(I.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
❑Agricultural ❑Municipal/Public ft. ft in.
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 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 applicable)'
FROM TO MATERIAL , ' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
f- ft.
❑Aquifer Test , ❑Stormwater Drainage -
ft. ft. i
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 f- , Red Clay
, 4,Datewell(s)Completed: 7/14/23 Well ID# 16 ft- 29 ft- Wet Red Clay
• 29 f- 55 ft- Wet Brown Dirt
Sa.Well Location: 55 f- 70 ft- • Brown Rock
Victoria Breedlove Properties,LLC
70 f- 245 f- Slate
Facility/Owner Name Facility ID//(if applicable)
4207 Clontz Taylor Rd„ Marshville 28103 ft. ft. Seams:s5',112=, 155',192�,209',
ft. 213—6gpm
Physical Address,City,and Zip 21.REMARKS
Union 03-111-010N : ' , ~$� ' ', r-,
County Parcel Identification No.(PIN) • • v.._�
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: N ►V 2 2 2023
22.Certification:
(if well field,one tat/long is sufficient)
N W Z7Gfiel--- 7i741.7atite- Inrc-i.--;.% -:-.1 T:),.-- •
8/17/23.:-:: :. ;;y ;i'. t'b"r.'$
SignatureWell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form.I hereby certiry that the wells)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 ElNo 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 I.
repair under 1121 remarks section or on the back of this 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
.9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtjferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 38 (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) 6 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013