GW1-2023-02652_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycuft FROM TO I DESCRIPTION
Well Contractor Name 1 48 f" 52 ft. 10 gpm
4070-A 190 fi- 200 fr. 25 gpm
OUTER CASING for multicased ovens 0 R 'Sfapplicable)
ER T.%�
NC Well Contractor Certification Number APR 1. 2023 FROM TO DIAMETER E� I MATERIAL
Derry's Well Drilling, Inc. 0 . t- 145 ft 161/8 1II1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
FROM TO DIAMETER TIUCKNESS I MATERIAL
2.Well Construction I Permit#: 22-329 ft. 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. in.
DAgricultural OMunicipaUPublic
DGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. in,
ClIndustriall'Commercial DResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
DMonitoring DRecovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Rernediation 19.SAND/GRAVEL PACKif applicablel
DAquifer Storage and Recovery OSalinity Barrier FROM ft. TO ft. MATERIAL I EMPLACEMENT METHOD
ElAquifer Test DStormwater Drainage ft. ft. I
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets ifnece I ssary)
DGeothermal(Closed Loop) ElTracer FROM TO DESCRIPTION(color,hardness,seiUnck type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 013ther(explain under 421 Remarks) 0 ft. 11 ft. Brown Dirt
4.Date Well(s)Completed: 1/9/23 Well ID# 11 ft• 23 ft. Brown Rock
23 & 225 & Slate
5a.Well Location, & ft.
Brian Benton/Emerald Pointe Realty ft ft. Seams:48'=1 Ogpm,79',89',101',
Facility/Owner Name Facility M#(ifapplicable) ft ft. 116', 156', 182', 190'=25gpm
6303 Hwy 205, Marshville 28103(New Salem Estates, Lt8)
ft. ft.
Physical Address,City,and Zip 21.RENIARKS
Union 01-144-012K
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/niinutestseconds or decimal degrees: 22.Certification:
(ifweU field,one hit/long is sufficient)
N W 2/1/23
Signature MCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the wells)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: OYes or 93No copy ofthis record has been provided to the well owner.
If this is a repair,fill out knmvn well construction information and explain the nature of the
repair under#21 remarks 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: 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: 225 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple ivells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,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
(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
13a.Yield(gpm) 35 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013