GW1-2022-10063_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:
John W. Huneycutt3 14.WATER TONES
n , y g ; FROM TO DESCRIPTION
Well Contractor Name Q -�^^a I 318 ft• 325 f`' I 1 gpm
2465-A N O V 0 7 2022 ft. &
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR
R if a livable
r,i`. ,-.y,_�„;•'';CI lint• FROM TO DIAMETER ! THICKNESS MATERIAL
Derry's Well Drilling, Inc. In;uc�r��, '� w . o it 45 f` 6 1/8 i SDR-21 _I PVC
Company Name 16.INNER CASING OR TUBING Eetithe'r mal closed-loo
21-335 FROM TO DIAMETER 1 THIMWSS MATERIAL
2.Well Construction Permit#: fr. ft.
List all applicable well pertnils(i.e.Cotmly,Stare,Variance,b jection,etc.)
& ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft in. +`
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT ;.
FROM TO MATERIAL !. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 f1• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft- Bentonite j` Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL'1' EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20•DRILLING LOG attach additional sheets if nccessa
[]Geothermal(Closed Loop) ❑Tracer . FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 7 ft f Brown Dirt
4/2/22 7 f`' 22 ft' �! Brown Rock
4.Date Wells)Completed: Well ID#
22 f`• 505 fr Blue Rock
Sa.Well Location: ft. ft. !'
DC Homes ft. ft. Seams: 78', 103', 135',202',214',
Facility/Owner Name Facility iD#(if applicable)
6226 Olive Branch Rd., Marshville 28103 ft. ft. 22l"i•,318'=1g,398',415',455'
f[. ft. 41
Physical Address,City,and Zip 21.REMARKS
Union 02-199-002D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one)at/long is sufficient)
96�& a,)- Fi
N W 4/6122
Si ture of Certified Well Contractor Date
6.Is(are)the we11(s): ©Permanent or ❑Temporary By signing this form,1 hereby cert!6,that the,trell(s)u-as(were)constructed in accordance
with 15A A'CAC 02C.0100 or 15.4 NCAC 01C.0100{Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been prorided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under-21 remarks section or oil the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to piovide additional well site details or well
S.Number of wells constructed: 1 i construction details. You may also attach additional pages if necessary.
For nudliple ityectian or non-water supply wells ONLY irith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di11erenl(example-3@100'and 2@100) construction to the following:
10.Static water level below top of casing: 34 (ft.) 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: (in.) 24b.For iniection Wells ONLY: In addition to sending the form to the address in
Rotary. 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method. 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)
1 Air 24c.For Water Supply
Method of test: &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 Qepartment of the county where
constructed.
Form GW-t North Carolina Department of Environment and Natural Resources—Division of Water Resources; Revised August 2013
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