GW1--05048_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 368 ft• 375 ft. 5 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap • ble)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 45 ft• 6 1/8 i°• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
24-93 FROM TO DIAMETER 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.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 applicabJ
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑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,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. Brown Dirt
4.Date Well(s)Completed: 4/17/24 Well ID# 8 ft• 385 ft• Slate
ft. ft.
51.Well Location: ft. ft.
Michael Sarullo
ft. ft. Seams: 75',90', 113', 134', 178',212',
Facility/Owner Name Facility ID#(if applicable) ft. ft. 255',269',299', 321',335', 368'=5g
4925 Dusty Ln., Marshville 28103 ft. ft.
Physical Address,City,and Zip
21.REMARKS ,_._ _-_ -_ _._ . _ -.
Union 01-117-003 ,. - ` ):- -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ;
N W L. � is f.'.:.-'S/15/24
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certifil that the well(s)was(were)constructed in accordance
with 1 5A NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 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: 385 (ft.) 24a. For All Wells: Submit this form 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:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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 m 5 Method of test: Air 24c.For Water Supply&Injection Wells:
(gpm) 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