GW1--05056_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 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name /-- ya „„ 372 ft, 376 ft• 2 gpm
4070-A I L'4--.I,"L:; ' e t1 411 ft• 415 ft• 1 gpm •
NC Well Contractor Certification Number '� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
AUG 0 i 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. - o it 49 ft• 61/8 in- SDR-21 PVC
Company Name q Into �rt'+s;iC1 ar,,.,r • 16.INNER CASING OR TUBING(geothermal closed-loop)
22-JGO ��dc�Jl -5° 4 Ur`a FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: 32 ft. ft. in.
List all applicable well permits(r.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
[Agricultural OMunicipal/Public ft in
OGeothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 L Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL E6iPLACEMENT11fET1rOD
ft. f4 ,
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rack type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 7 rt. Wet Red Clay
1/28/23 - .7 ft• 29 ft• Brown Dirt
4.Date Well(s)Completed: Well ID#
29 it 425 ft• Slate
5a.Well Location: ft. ft.
Deer Run Farm, LLC ft. ft.
Facility/Owner Name Facility LW(if applicable)
6314 Huggins DairyRd,Marshville 28103(The Reserve at Huggins Dairy,Lt6 ft. 2 Seams:56',74',93, 118, 197,234,277,
99 99 ) ft. ft
• 344',372'=2gpm,389',395',411-,_
1 gpm
Physical Address,City,and Zip 21.REMARKS
Union 03-039-004J
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 DU L. r t u uG 2/15/23
Signature o Certified Well Contractor Date
6.Is(are)the well(s): 2IPermanent or OTemporary By signing this form,I hereby certiO that the well(s)was(were)constructed in accordance
- with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction ihformation 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: 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: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" I 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
3 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:_ _ 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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