GW1-2021-05838_Well Construction - GW1_20210709

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 A FR WATER ZONES y
_ fin"1 FROM TO I DESCRIPTION '
Well Contractor Name `1 1` bb v Ott 157 165 f4 { 3 9Pm
4070-A Jv p ��sg�n9 ft ft.
1N
NC R
tell Contractor Certification Number t10� O �Y 0(� 15.OUTER CASING for lti-cased wells OR LINER if a licable
�C((,3 �5e�
{ A y FROM mu
TO DIAMETER! THICKNESS ATERiAL
Derry's Well Drilling, Inc. !J 0 ft- 45 ft 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
21-43 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t<• 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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 1CResidential Water Supply(single) ft' R
❑industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 tt. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- BentonitePumped
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Ofapplicable)
FROM TO MATERIAL, EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tL 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.soittrork IyM grain si de.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 11 ft. Brown Dirt
4.Date Well(s)Completed: 5/17/21 Well iD# 11 ff 400 ft- Slate
ft. ft.
5a.Well Location: ft. ft.
Barbara Pine/Tammy Ross fL rL
Facility/Owner Name Facility to#(if applicable)
rL ft. Seams:'66',95', 114', 123', 135', 15T=3g
5502 Old Goldmine Rd., Marshville 28103
fL rL
Physical Address,City,and Zip
21.1tEMAR[iS
Union 01129005B
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one Iatllong is sufficient) '
N w
,c_. G� 6/5/21
Signature ot'(79fified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s),was(rvere)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 END 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 r21 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,
hor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMPfTAL INSTUCTiONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths ifdijjerenl(example-3t_a7,200'and 2@ 100) construction to the following:
10.Static water level below top of casing- 46 (ft,) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Ceq'ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.anger,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
132.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Yells:
Also submit one copy of this form I 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 ofEnvironment and Natural Resources—Division of Water Resources I Revised August 2013
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