GW1-2022-10044_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells _
1.Well Contractor Information:
14.WATER ZONES .
John W. Huneycutt FROM TO DESCRIPTIONI
Well Contractor Name r , "°-- 309 ft 315 fG 12 gpm
rr�� v� fG % f
NC Well Contractor Certification Number N O V V t 2022 15.OUTER CASING for tnniti-cased wel •OR LINER if a livable
FROM TO DIAMETER!' i TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. r_ i r^�r ;ng urd" 0 rt• 45 ft- 61/8 j' SDR-21 I PVC
Company Name DAAl OJ i 7 16.INNER CASING OR TUBING(geothermal closed-loop)
22-004 FROM TO DIAMETER TMCKNESS MATERIAL
2.Well Construction Permit#: ft ft
List all applicable ivell permits f.e.County,State,Variance,Injection,etc.)
ft % in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MAft. fL
TERIAL
❑Agricultural ❑ cMunicipal/Publi in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft
❑lndustriaYCommercial ❑Residential Water Supply(shared) 18.GROUT
.FROM TO. MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring oRecovery 3 ft 20 fG Bentonite. Pumped
Injection Well: ft. ft
❑Aquifer Recharge . ❑Groundwater Remediation '19.SAND/GRAVEL PACK if applicable)
FROM TO I IVIATERIUL EMPLACEMENT ATETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
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❑Aquifer Test ❑Stormwater Drainage ft. it. t.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock ain shr,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 amaJ 0 ft. 20 ft. Brown Dirt
5/23/22 20 ft• 325 fL l Blue Rock
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: - ft. ft
CMH Homes Inc. ft. ft.
Facility/Owner Name Facility ID#(if applicable) fG ft. Seams: 56',75',85', 105',120',152',
6524 E Lawyers Rd., Marshville 28103 ft. ft 1971;216',271',285',309'=12gpm
Physical Address,City,and Zip 21.REMARKS
Union 02-167-004B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) i
N 6/4/22
Si cure of Certified Well Contractor Date
6.Is(are)the weU(s): ©Permanent or ❑Temporary By signing this form,i hereby certify that the ivell(s)'vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to lhe;ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the I'
repair under 421 remarks section or on the back ofthis form: 23.Site diagram or additional well details:
You may use the back of this page toy provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or nonavater supply wells ONLY with the same construction,you can
submit one form. SUBIIIITI'AL INSTUCTIONS
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9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple'vells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 18 (ft.) Division of Water Resour,Ices,information Processing Unit,
If'vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: to addition to sending the form to the address in
Rota 24a above, also submit a copy of is 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 Cen er,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: Air
24c.For Water Supply&Iniection 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 iepartmcnt of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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