GW1-2023-01616_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:
Derry L. Huneycutt 14.WATER zoNES I €
FROM TO DESCRIPTION
Well Contractor Name 105 ft 110 ft. 60 gpm
2663-A `� �t-'gym' `V Gy "' ft ft
NC Well Contractor Certification Number FEB 3 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICIQIESS MATERIAL
Derry's Well Drilling, Inc. o n 53 ft- 61/8 ; 6CR-21 I PVC
Company Name Its! :?• e 16.INNER CASING OR TUBING eothermal closed-loop)
22-300 °1Q';30G FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: ft & in:
List all applicable well permits(i.e.County,State,Variance,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. i
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in. �:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
- 3 ft 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
ft ft „
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rack a 'n size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Brown Dirt
11/8/22 15 ft 125 fr. ;; Slate
4.Date Well(s)Completed: Well EN ft ft
5a.Well Location: & ft.
Paul Smith ft ft
Facility/Owner Name Facility ID#(if applicable)
ft & Seams: 98', 105-110'=60gpm
RA Austin Rd., Marshville 28103 & ft
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Physical Address,City,and Zip 21.REMARKS
Union 01-051-013
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W D 11/17/22
Signature of C ' ed Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that lire 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 0No copy of this record has been provided to the 1,711 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
8.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 farm within 30 days of completion of well
For multiple wells list all depths ifdiocrent(example-3@200 and 2(6100) construction to the following:
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10.Static water level below top of easing: 16 (ft.) Division of Water Resources;Information Processing Unit,
ffwater level is above casing use"+" 1617 Mail Service Center'iRaleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of thi I form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY•' 1636 Mail Service Center,;Raleigh,NC 276994636 13a.Yield(gpm) 60 Method of test: Air I,
lls:
24c.For Water Supply&Infection Wells:
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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 healthy department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resoul rces Revised August 2013
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