GW1-2022-10074_Well Construction - GW1_20221107

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: p
This form can be used for single or multiple wells j
1.Well Contractor Information:
Dwight L. Huneycutt FR MATERONES' DESCRIPTION I`
Well Contractor Name .o � dj9 A 428 'L 430 f- 50gpm
4070,=A ti E ,`4r �y qyq ft. f,
NC Well Contractor Certification Number N O y 0 t 2022 L 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER i. TffiCrdVESS MATERIAL
Derry's Well Drilling, Inc. _ ; c,. ;Urt 0 ft. 46 ft 61/8 i°j:, . SDR-21 PVC
Company Name 16.INNER.CASING OR TUBING eothermal closed-loop)
Ji!:rQlr
22-180 FROM TO DIAMETER I THICravFss MATERIAL
2.Well Construction Permit#: f, ft. m
List all.applicable well permits(1.e.County,State,Parlance,Injection,etc.)
ft. ft. in.,,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 fL '20 ft' Bentonite Pumped
[]Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sailtrack typN sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under*21 Remarks) 0 ft. 11 ft. Brown Dirt
7/23/22 11 ft- 22 ft- Brown Rock
4.Date Well(s)Completed: Well ID#
22 rt. 445 fr. Slate
5a.Well Location: ft. ft.
Kyle Griffin ft, ft.
Facility/Owner Name Facility IDII(if applicable)
5d25 Dusty Ln., Marshville 28103 c� ft- Seams:68',7T,90', 111',115', 12T, 175',
289',428-430-50gpm
Physical Address,City,and Zip 21.REMARKS
Union 01144033B
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)
N W DG�CertifiedP � 8/11/22
Signature of Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 br 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the ive l owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remark section or on the back ofthis 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 ONLYwith the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
11
10.Static water level below top of casing: 20 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter Rotary 6 (in.) 24b.For Infection 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: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) ,
Division of Water Resources,Uuderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen"ter,Raleigh,NC 276994636
13a.Yield(gpm) 50 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013