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GW1-2021-05880_Well Construction - GW1_20210709
i IL WELL CONSTRUCTION RECORD For internal Use ONLY: This form can be used for single or multiple wells f 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 I 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. i Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013 f i