GW1-2021-04514_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: k
This form can be used for single or multiple wells
1.Well Contractor Information:
1 WATER ZONES
Dwight L. Huneycutt FROM
DESCRIPTION
Well Contractor Name �q 72 n' 76 25 gpm
4070-A ll.�� Q 2ot1 it• ft.
NC Well Contractor Certification Number p �j e1 15.OUTER CASING for multicased wells OR LTNER it a livable
H M TO DLVI7ETEIt TffiCKNFSS MATERIAL
Derry's Well Drilling, Inc. �, vices ►ng o rt• 50 n 6 1/8 i° SDR-21 I PVC
Company Name r` '`^,IR Se 16.INNER CASING OR TUBING eothermal closed-loop)
V 1�i i"t� v FROM TO DIAMETER THICKNESSMATERIAL
2.Well Construction Permit#: 20-487 ft, ft. in.
List all applicable ivell 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 SITE TWCKVESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipalftblic
❑Geothermal(Hcating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustnal/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it• 35 ft• Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Fxperimcntal Technology ❑Subsidence Control
20.DRII.LING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION wlor,l irda wi0rork type,grain sue etc.
❑Gcothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) 0 it- 14 ft' Brown Dirt
1/20/21 14 ft 21 ft Brown Rock
4.Date Well(s)Completed: Well ID#
21 ft 125 ft Slate
5a.Well Location: ft. ft
Carroll L. Rushing
Facility/Owner Name Facility ID#(if applicable)
7010 White Store Rd., Marshville 28103 Seams: 5s�,65',72-76'=25gpm
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 02129001 E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w
2/15/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACA2C.0100 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the uoell owner.
Ijthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ojthis 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: (ft.) 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 Iniection Wells ONLY: In addition to sending the form to the address in
Rota 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,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) 25 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.
Form GW-1 North Carolina Department of Envirortrnent and Nan°al Resources-Division of Water Re sot uces Revised August 2013
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