GW1-2021-05880_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor information:
Dwight L. Huneycutt �'�� FRFR WATER ZONES
��' OM TO DESCRIPTION
Well Contractor Name 130 ft. 136 ft I 10 gpm
4070-A 11� 9 TO ft ft.
J 1 5.OUTER CASING for multi cased wells OR LINER if a licable
NC Well Contractor Certification Number V
ptocesS�n9 FROM TO DIAMETER THIt70NESS MATERIAL
Derry's Well Drilling, Inc. ^u, n �c..on 0 ft. 49 ft 6 1/8 in SDR-21 PVC
1 I{ (J rPe Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
AA
21-49 FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: ft. ft. is
List all applicable well permits(I.e.County,Stale,Variance,Injection,etc.)
[t. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7E THICKNESS MATERIAL
-❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 for. 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Saliniq'Barrier R. 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,sei1lr"k rain sia,eta
❑Geothermal Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft. 16 ft Brown Dirt
4.Date Well(s)Completed: 4/6/21 Well iD# 16 ft. 225 ft. Slate
ft. fL
5a.Well Location: ft ft
Ron Rushing Construction ft. ft.
Facility/Owner Name Facility JEM(ifapplicable) fL. ft
5805 Fish Rd., Marshville 28103 (Damon Hills Lt6) Seams:69', 108', 117', 130'=log
rt. for.
Physical Address,City,and Zip 21.REMARKS
Union 01087008F
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W �G � 4/21/21
Signature of Certitied Well Contractor Date
6.IS(are)the well(s): ©Permanent or ❑Temporary By,signing this fornt,I hereby certify that the well(s)was(mere)constructed in accordance
with 15A N(:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well miner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under H21 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit ane form SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
Nor multiple wells list all depths ifdifferem(example-3@200'and 2@100') construction to ate following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,information Processing Unit,
Ifwater level is above caring use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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IL Borehole diameter. 6 24b.For Infection Welts ONLY: MI UUUition 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
13a.Yield(gpm) 10 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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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