GW1-2022-04348_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt �?_� .'_I' h:- 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name / 169 ft• 175 ft 30 gpm
4070-A �- . R 11 202_ fL ft.
NC Well Contractor Certification Number ,: ,^;;4; y' j 15.OUTER CASING for multi-rased wells OR LINER if a ticable
ti r FROM TO DL►METER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. 1 ;�: ?iCr < �'=f� ,� 0 63 f 6 1/8 1°• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING ,,`thermal closed-loop)
10012360 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL 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 I MATERIAL
❑Agricultural ❑MunicipaUPublic ft % in:
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft• fL in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 3 ft• Bent.Chips Gravity
❑Monitoring ❑Recovery 3 fL 35 fL Bentonite Pumped
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fif.,nlicablel
FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft.
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardaa .oiVrock tyM grai.e' eta
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 0 fL 13 ft. Red Clay
4.Date Well(s)Completed: 12/14/21 Well ID# 13 ft- 35 % Brown Dirt
35 fL 55 ft• Brown Granite
5a.Well Location: 55 ft 188 & Blue Granite
Vladimir Melnichuk 88 ft• 112 IL Brown Granite
Facility/Owner Name Facility ID#(if applicable) 112 fL 185 fL Blue Granite
4021 David Dr., Matthews 28105 fL ft. Seams: 150', 169'=30g
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 195-013-02
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) ' f
N w 1/20/22
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 NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this 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 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 INSTUCTIONS
9.Total well depth below land surface: 185 (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: 25 (fL) 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 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.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 27699LI636
13s.Yield(gpm) 30 Method of test: Air 24e.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