GW1-2023-01617_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal Use ONLY: l
This form can be used for single or multiple wells
1.Well Contractor Information:
DWI ht L. Huneycutt 14.WATER ZONES ' [ f
9 Y �.F�T F'\ FROM TO DESCRIPTION I
We It Contractor Name s ` 136 145 ft' I I 1 gpm
4070-A FEB 1 2023 ft. &
NC Well Contractor Certification Number 15.OUTER CASING for multi used wells'OR LINER if a tica6le
Derry's Well Drilling, Inc. ;:�? '=�1.!r ,t FROM � s 8ETER p I TluclavEss nrATERLAL
y 6 ft ft. in
�tr�r �• ,, SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(2eatbirmal closed-loop)
22-96 FROM TO DIAMETER I THICK NEss MATERIAL
2.Well Construction Perotit#; ft ft lm
List all applicable well permits(1.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 TIHCKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft ft
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
.❑lrri ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite' Pumped
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To AtATERLIL ' EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft I�
❑Experimental Technology ❑Subsidence Control
20.DRII.LING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,haidv soil/rack type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 18 ft Brown Dirt
4.Date Well(s)Completed: 9/27/22 Well ID# 18 ft 24 ft ;, Brown Rock
24 ft- 500 ft- Slate
Sa.Well Location: ft. ft 1,
Steven Outen ft rt
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Facility/Owner Name Facility ID#(if applicable) ft. ft Seams:52';56',78',95', 111', 136'=1 gpm
6426 Shelf Rd., Marshville ft ft
Physical Address,City,and Zip 21.REMARKS
Union 02-098-012B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutesAcconds or decimal degrees: 22 Certification:
field,one lat/long is sufficient) i
N W T�GuLZ-,L.. u�ZQ.u� 10/20/22
Signature a ertified Well Contractor Date
6.Is(arc)the well(s): RIPermanent or ❑Temporary By signing this form,I hereby certo that the"well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Jor ONo copy ofthis record has been provided to the well bwner.
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: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100) construction,to the following:
10.Static water level below top of rasing: 56 (fG) 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- 6 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: Rotary construction to the following: !j
(Le.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 276994636
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13s.Yield(gpm) 1 Method of test: Air
24c.For Water Supply&Injection Wells
Also submit one copy of this form within 30 days of completion of
13b.Disinfectiontype: Granular Amount: 1/2 lb• well construction to the county health department of the countywhere
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water ResourM Revised August 2013