GW1-2022-04350_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single at multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name APR 11 702? 170 f- 178 fob 75 gpm
4070-A ft ft.
NC Well Contractor Certification Number IS.OUTER CAST!NG for multi-easedtwells) icable)
FROM TO I DIAMETER O�=api MATERIAL
iu J 1 LAME r
Derry's Well Drilling, Inc. 0 ft' 184 fit- 161/8 � '- I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(26othermal closed-loov)
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 10011934 ft. It.
in.
I List all applicable well permits(i.e.County,State,Ilartance,Injection,etc.) ft. f, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
CAgricultural CMunicipal/Public ft. ft in.
DGeothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
01ndustrial/Commercial CResidential Water Supply(shared) I&GROUT
FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
DMonitoring ORecovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
ElAquifer Recharge OGroundwater Remediation I9.SAND/GRAVEL PACK 01'aprilicable)
ElAquifer Storage and Recovery USalinity Barrier ft.
FROM TO MATERIAL CEMENT METHOD
CAquifer Test OStormwater Drainage ft. ft
[] .
Experimental Technology USubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.bardnes3,soillrockqM gmin sae,etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks)
0 ft- 33 ft Red Clay
4.Date Well(s)Completed: 3/4/21 well RM 33 f- 56 ft. Brown Clay
56 ft- 75 ft. Brown Granite
Sa.Well Location: 75 ft' 1185 ft' Blue Granite
Joaquin Lopez Lucero ft. ft.
Facility/Owner Name facility ID#(if applicable) ft. ft. Seams:92', 150', 170'=75g
8821 Vagabond Rd., Charlotte 28227 17L
Physical Address,City,and Zip 21.REIdARKS
Mecklenburg 139-271-52
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/niinutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W rl/aw-'U�_ 3/25/21
Signature ot'Ce-rtified Well Contractor V Date
6.Is(are)the well(s). [OPermanent or OTemporary By signing this form,I hereby certify that the well(v)was(.Pere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well ConsiructionSlandards and that a
7.Is this a repair to an existing well: ElYes or END copy ofthis record has been provided to the well owner
li"this is a repair,fill out known well conviruction information and explain the nature of the
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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTITMONS
9.Total well depth below land surface: 185 (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
I-br multiple wells list all depths ifafifferent(example-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: 9 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: Th 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 27699-1636
13a.Yield(gpm) 75 Method of test: Air 24c.For Water Supply&injection Wells
Also submit one copy of this form 1within 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