GW1--05051_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt t--� ;:.� 14•WATER ZONES i
a $"^t. ,, FROM TO DESCRIPTION
Well Contractor Name '- `{�-4..#i..® V 269 ft 275 ft- 3 gpm
4070-A A I I( A ft. ft.
NC Well Contractor Certification Number li lJ l7 0 20�3 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. Inklr'a:7:.,. ' P"2 1 ' Ur;rh` 0 ft 44 ft- 61/8 in- SDR-21 PVC
`,,'"'i�`�'� 16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 20-74 ' 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: I FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑IndustrialCommercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
-
❑Irrigation 0 ft. 3 ft- Bent Chips Gravity
Non-Water Supply Well:
pMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El 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/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 17 ft. Brown Dirt
6/29/23 17 f• 300 ft Slate
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Exemplor Homes ft. ft ,
• Seams:56',78', 111',149', 190',216',
Facility/Owner Name Facility ID/i(if applicable)
High Ridge Church Rd, Marshville 28103 ft. ' ft. 257',269'=3gpm
2533
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 02030003
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W DGU 7/25/23
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA 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 well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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: 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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3 a(�00'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) 3 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013