GW1-2021-04601_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: !
This form can be used for single or multiple tvel►s I
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1.Well Contractor Information:
Dwight L. Huneycutt `A' W 14.WATER ZONES
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DESCRIPTION
Well Contractor Name �j lg n' 8 gpm
4070-A 9 L` n.
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NC Well Contractor Certification Number �� Sep\n�JG for multi cased wells OR LINER it o licabie
P Q�e FROM TO DIAMETER TMCKII•ESS nI►rERIAI
Derry's Well Drilling, Inc. (\Q( eC' 0 n 145 n 61/8 1 In SDR-21 I PVC
t ( , 16.INNER CASING OR TUBING eothermal closed-moo
Company Name d 0 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 10011�� n. n i°•
List all applicable ivell permits(i.e.Count,State,Variance,Injection,etc) n n in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well- FROM TO DIAMETER I SLOT SI29i THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public [-----+
n.
❑Gcothermal(Heating/CoolingSupply) ORcsidential Water SuPP1Y(single) n• ft. inn..
❑Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ETH'LACEIIIENfMETHOD&AMOUNT
❑Irri ation 0 n. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 n 35 n Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applicable).
FROM TO MATERIAL EnNiPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier h. n.
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets H necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
❑Geothermal Latin Coolin Return ❑Other(explain under#21 Remarks 0 n. 65 n Brown Dirt
11/25/20 65 n• 135 n• Brown Granite
4.Date Well(s)Completed: Well ID#
135 n 300 n Blue Granite
5a.Well Location: n. n. i
Carol Pettigrew
Facility/Owner Name Facility iDt#(if applicable)
Sea
8801 Vagabond Rd., Charlotte 28227 Seams: 152', 155-170', 171',255'=8g
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 130-271-•40
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/miuutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W � � 12/15/20
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constricted in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the well owner.
If this is a repair,fill out knormr well constnction information and explain the nature of rite
repair tinder i#11 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 oneform. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 300 (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:
10.Static water level below top of casing: 22 (g,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection 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.auger,rotary,cable,detect 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) 8 Method of test: Air 24c.For Water Supply At Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular well construction to the county health department of the county where
13b.Disinfection type: Amount: 1/2 l b.
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resomwces Revised August 2013
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