GW1-2022-10051_Well Construction - GW1_20221107

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
- 1
9 Y FROM TO DESCRIPTION I
Well Contractor Name- e* 41.=- 151 ft- 155 ft' I j 2 gpm
4070-A In.. y� ft ft
NC Well Contractor Certification Number NOV n , 20�� 15.OUTER CASING for multi-cased wells OR LiNER if a licable
Y 0 � FROM TO DIAME77;R 1 1 THICIINESS MATERIAL
Derry's Well Drilling, Inc. 0 ff- 85 ft.
6 1/8 SDR-21 PVC
Company Name if,,cr. iaa e.3 1 Pr`,-, y t` r� 16.INNER CASING OR TUBING eothermal closeddoo
22-130 D iOI OG FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it ft in. '
List all applicable well permils(i.e.County,Stale,Variance,Injection,etc) ft. ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
fL
❑Agricultural ❑Municipal/Public ft in.
❑Geothemral(Heating/Cooling Supply) EIResidential Water Supply(single) ft it
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 3 it Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 IL Bentonite;' Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT AIETHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sail/rock typr,grain size etc
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks 0 ft- 36 ft Wet Brown Dirt
6/17/22 36 ft- 75 ft is Soft Brown Rock
4.Date Wells)Completed: Well ID#
75 ft 425 ft Slate
5a.Well Location: tt ft. h
Joseph Bauer ft. n•
Facility/Owner Name Facility ID#(if applicable)
Stateline Rd., Marshville 28103 ft rt. Seams: 95',130', 151'=2g
ft ft 1
i,
Physical Address,City,and Zip 21.REMARKS
Union 03-114-009G
County Parcel Identification No.(PIN)
I„
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: I
22.Certification: 6
(if well field,one IaUlong is sufficient)
N W 6/4/22
Signature of Certified Well Contractor Date
I,
6.Is(are)the well(s): ©Permanent 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 EJNo copy of dtis record has been provided to lite ii,ell au ner.
If this is a repair,fill our known well construction information and explain the nature of the ;'
repair under 421 remarks section or on the back of this fonn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(eiample-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,:Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 24b.For iniection 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,ctc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health)I department of the county where
constructed.
Form GW-I North Carolina Departtuent of Environment and Natural Resources-Division of Water Resources Revised August 2013