GW1-2022-03886_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES k
FROM TO DESCRIPTION
Well Contractor Name 170 ft- 180 ft 6 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for maht cased wells OR LINER if a livable
FROM TO DIAMETER THICIQHFSS MATERiAr.
Derry's Well Drilling, Inc. 0 ft 45 fit- 6 1/8 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING 'thermal closed-too
115261 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R. in-
List all applicable well perinits(i.e.County,State,Variance,Injection,etc)
R. I ft. I im
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft ft
❑Agricultural ❑Municipal/Public . ft. io
n.
ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) iS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 tt 35 fit- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity=Barrier FROM ft TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. FL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn"s,soitIrock rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 15 ft. Brown Dirt Rock
4.Date Wcll(s)Completed: 8/6/21 Well iD9 15 ft• 21 ft Brown Rock
21 ft- 225 f`- Slate
Sa.Well Location: ft. ft.
Carlisle Rev Liv Family Trust ft. ft.
Facility/Owner Name Facility iD#(if applicable)
rL rL Seams: 60',72', 170'=6g
Herrin Grove Rd, Mt. Pleasant 28124 ft ft.
227'=7g
Physical Address,City,and Zip 21.REMARKS
Stanly 1661 =
County Parcel identification No.(PiN) APR
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
N W [/C�Jy// /�� :ll
Signature ofC rt tied Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this firm,1 hereby certify that the well([)was(were)constructed in accordance
with 15A MAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E3No copy cf this record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under r 21 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 one form. SUBMITTAL INSTUC`IONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple wells list all depths ifdijferent(example-3@200'and Zen 100) construction to the following:
10.Static water level below top of casing: 38 (ft,) Division of Water Resources,information Processing Unit,
!%water level is abate caring,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For injection Wells ONLY: in addition 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.field(gpm) 6 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i