GW1--07679_Well Construction - GW1_20231122

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 ,i
FROM TO DESCRIPTION I
Well Contractor Name 336 ft 340 it I 1/2 gpm
4070-A f4 t• I -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER f ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 96 ft 61/8 in. SDR-21 .PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-297 FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
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
❑Agricultural °Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) lrlResidential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
❑Irrigation • 0 ft. 3 n Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft 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 EMPLACEMENTIIlETHOD
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 size,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft• 25 ft. Red Clay
4.Date Well(s)Completed: 10/10/23 Well ID#2 25 rt• 49 ft- Brown Dirt
49 ft• 88 ft :Brown Rock&Quartz
5a.Well Location: 88 ft 600 ft •
I Slate
Victoria Breedlove Properties,LLC ft ft.
Facility/Owner Name Facility 11)11(if applicable) , , •
4207 Clontz Ta for Rd, Marshville 28103 ft. ft. Seams: 107', 112', 118',172',
Y ft. ft. 336'=1/2gpm
Physical Address,City,and Zip 21.REMARKS
Union 03-111-010N T ""
County Parcel Identification No.(PIN) l }lc •:•,' " yfn1 ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �f�')V b 2l'23
22.Certification:
(if well field,one lat/long is sufficient)
Z7 ,�, in,-0%17/23� P �' f':,-.3••-Y,
N W G2h 1...,. ..�,.,1 3'
Signature of Certified Well Contractor Date
6.Is(are)the well(s):©Permanent or ❑Temporary
By signing this form,1 hereby certfy that the well(s)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: ❑Yes or MNo 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#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:600 (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: 1,
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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) 1/2 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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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