GW1-2023-01604_Well Construction - GW1_20230214

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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:
Dwight L. Huneycutt 14.WATERZONEs
g FROM TO I DESCRIPTION I
Well Contractor Name 118 ft. 122 ft' I 60 gpm
4070-A ft it. i
NC Well Contractor Certification Number 15:OUTER CASING for multi-cased wells OR LINER if a livable
�a «_- e!Z rt- - FROM TO DIAMETER !I TffiCRNESs MATERIAL
Derry's Well Drilling, Inc. ,�—ti � io ft 46 ft• s vs SDR-21 PVC
Company Name _ 66 16.INNER CASING OR TUBING eothermal closed-loo
22-331 FEB1 J. 2023 FROM TO DIAMETER TMCKNFSS MATERIAL
2.Well Construction Permit#: ft ft rn
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
1 t ft. & in.
- ini's.r��%rrl.,c+"1 rt...•.i�G.Ft� ✓n[ !.
3.Well Use(check well use): ;'e`I % ! 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11
❑Agricultural ❑Municipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑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:
3 ft 20 fr. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK if a livable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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 DFSCRn'TION e'emr hardu soi0rock type size,etc'
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft ;I Brown Dirt -
10/15/22 11 ft 25 ft. ' Brown Rock
4.Date Well(s)Completed: Well ID#
25 ft 12$, ft- ! Slate
5a.Well Location: ft ft.
Brian Benton/Emerald Pointe Realty
ft ft
Facility/Owner Name Facility M#(if applicable)
Hwy 205, Marshville 28103 (New Salem Est, Lot 10) ft rt Seams:60',68',76-82', 118-122'=6ogpm
f. ft
Physical Address,City,and Zip
21.RF.MARKR _
Union 01-144-012
County Parcel Identification No.(PIN)
I.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one tat/long is sufficient)
N W T��urlLt,L. 11/5/22
Signature ofCertified Well Contractor +, Date
6.Is(are)the well(s): 1OPermaneat or ❑Temporary
13y signing This farm,1 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 EINo copy of this record has been provided 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 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
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: 125 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
!
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this ifoim within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method oftesN Air 24c.For Water Supply&Injection Wells;:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 ib. well construction to the county health department of the county where-
constructed.
Form GW-I North Carolina Department ofEavironment and Natural Resources—Division of Water Resources Revised August 2013