GW1-2022-04306_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 1RwATERZONES
FROM TO I DESCRIPTION
Well Contractor Name _ 7_ --. 135 f� 139 R' 3 gpm
� �`T1 .J
4070-A .,� _. ft. fL
NC Well Contractor Certification Number An r� /p IS.OUTER CASING for multi cased wells OR LINER if a licable
A P Q o 8 2022 FROM TO DIAMETER THIC7a I MATERIAL
Derry's Well Drilling, Inc. 0 ft- 174 ft 16 1/8 SDR-21 I PVC
R CASING OR TUBING(geothermal closed-loop)
Company Name 16.INNE
ROM TO DIAMETER TIDLTINBSS MATERIAL
2.Well Construction Permit#: 21-316 ','�'1 i i l 'd � :�'
fL ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
ft ft. 'in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCIUWM MATERIAL
❑Agricultural ❑MunicipaUPublic fL fL in,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL it
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 fL 35 fL 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 ❑Salinity Barrier fL fL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIPTION color,hardness soillrock type,grain si2r,etc)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rL 5 & Wet Red Clay
4.Date Well(s)Completed: 2/3/22 well ID# 5 ft. 19 fL Brown Dirt
19 fL 35 f' Brown Rock
5a.Well Location: 35 ft' 65 fL Junky Blue Rock
Donald Coleman 65 fL 365 sc Slate
Facility/Owner Name Facility ID#(if applicable) rL ft.
6521 East Lawyers Rd, Marshville 28103 % Seams: 135-139'=3g, 148',212',309'
Physical Address,City,and Zip 21.REMARKS
Union 02-167-004
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(if well field,one Wong is sufficient)
N W 2/25/22
Signature o ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 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 owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 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
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 INSTUCPIONS
9.Total well depth below land surface: 365 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijfereni(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of using: 47 (N Division of Water Resources,Information Processing Unit,
Ifwater 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
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) 3 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