GW1-2023-01672_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 FROM
TER ZONES 1
ROM TO DESCRH'TION
Well Contractor Name ' G 3 gpm
4070-A ' '^;' 8 �" 296 ft 300 ft
!� � � � 2 gpm
NC Well Contractor Certification Number FEB 1 '4 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER I THICKNESS MATERIAL
023
Derry's Well Drilling, Inc. ]niti rr�. c{ 0 ft 52 f4 6 1/8 SDR-21 PVC
n s•T_ :^: / 16.INNER CASING OR TUBING eothermal closed-loo"Company Name ��`a �^�',r n '�t!i ,
22-230 its FROM TO DIAMETER 1 THICKNESS MATERIAL
2.Well Construction Permit#: ; G J ft. ft li in;
List all applicable well perms?s r.e.County,State,Pariance,Injection,etc.) -----d
ft. ft. fj in
3.Well Use(check well use):
17.SCREEN It
Water Supply Well: FROM TO DIAMETER 1,SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in. it
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft 1°
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: it ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft TO MATERIAL I I EMPLACEMENT METHOD
❑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(cohr.hardness.soil/rack type.grain srzqua
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks 0 ft- 25 it. I Brown Dili&Rock
8/19/22 25 fL 35 fL Shale
4.Date Well(s)Completed: Well IDt/ 35 ft 325 ft I I Slate
5a.Well Location: fL &
Zach Taylor rt &
Facility/Owner Name Facility ID#(ifappllcable) Seams:,67%70',86',93', 114', 147', 155',
6201 Bunn Simpson Rd., Marshville 28103 ft. ft 170',1,93',213',227-235'=3gpm,250',
p ft ft 1270%277%296'=2gpm
Physical Address,City,and Zip 21.REMARKS
Union 01-066-009C
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County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
('dwell field,one lat/long is sufficient) /
N W `Qy 8/31/22
Signature of`05itified Well Contractor ! Date
6.Is(are)the well(S): 101ermanent or ❑Temporary by signing this form,i hereby certify that die wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C,b200 Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or RlNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain Cite mature 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 INSTUCfIONS
9.Total well depth below land surface: 325 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdifferent(example-3Q200'and 2@100) construction to the following:
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10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
ifrvater level is above casing,use"+' 1617 Mail Service Centel,Raleigh,NC 27699-1617
11.Borehole diameter; 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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:
(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
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13a.Yield(gpm) 5 Method of test- 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 lb. well construction to the county health'department of the county where
constructed.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013