GW1-2021-05869_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune curt F14.
RWATERZONES
g Y _ ®�'�' FRODf TO I DESCRIPTION
Well Contractor Name 112 R' 120 R' j ! 60 gpm
4070-A
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased wells OR LINER ilap
Gcable
TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. PrI .. 1p 0 n. 150 n• 6 1/8 i i° SDR-21 PVC
Company Name h U I " D�R� -' 16.INNER CASING OR TUBING(geothermal closed-loop)
To DIA711ETER THICIGVESS DATERIAL
2.Well Construction Permit#: 21-129 FROM n. n. in.
List all applicable well permits(i.e.Cormt),,State,Variance,Injection,etc.)
n. n. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESs MATERIAL
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❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal eatin Coolin Supply) ❑Residential Water Supply(single) n. n• in.
(H � g PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I To MATERIAL EDIPLACEDIENT METHOD&AMOUA r
alai ation 0 n. 3 R• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 R 35 ft Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n n.
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionol sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R. 14 R Brown Dirt/Rock
4.Date Well(s)Completed: 4/19/21 well ID# 14 R' 185 R' Slate
tL n.
5a.Well Location:
David M. Bullington n. n.
Facility/Owner Name Facility ID#(if applicable) n.
Behind 6625 Old Kennedy Ford Rd, Marshville 28103 n Seams:s9�,74�, 112�=sOg
Physical Address,City,and Zip 21.REMARKS
Union 01054006,01054007
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/miuutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N `tl, T�rrr; et,L_. 5/4/21
Signature of tertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)tvas(were)constructed in accordance
with I SA NCAC 01C.0100 or I SA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the well owner.
If this is a repair,fill out known well consmictiion information and explain the nature of the
repair tinder#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,ymt can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 185 (ft.) 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:
13 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
If uuter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241b.For Iniection Wells ONLY: 1n addition to sending the form to the address in
Rotary 24a 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
I
13a.Yield(gpm) 60 Method of test: Air 24c.For Water Supply&Injection!Wells:
Also submit one copy of this form within 30 days of completion of
Granular well construction to the county h�lth department of the county where
13b.Disinfection type: Amount: 1/2 Ib. �.
constructed. '
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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