GW1--01912_Well Construction - GW1_20240325

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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:
l 14.WATER ZONES
Dwight L. Huneycutt 1 ,---,„ FROM TO DESCRIPTION _ ,
Well Contractor Name '1,' sue,,,, ..,,; ��r 75 ft. 77 ft. I 1 gpm (92-95' lgpm)
4070-A MAR 2 ii 2024 115 ft• 121 ft, 4 gpm (125-135'=96gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER ` THICKNESS MATERIAL
• Derry's Well Drilling, Inc. lnfii;`"-" ;n,'''rsR�;:a j�n 0 ft. 45 ft• 6 1/8 in• SDR-21 PVC
Corn Name ✓. a'-' 16.INNER CASING OR TUBING(geothermal closed-loop)
Pan
23-236 FROM TO DIAMETER • THICKNESS MATERIAL
2.Well Construction Permit#: 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
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft R [n
❑lndustrial/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 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 ❑Salinity Barrier
ft. ft.
❑Aquifer Test :StormwaterDrainage ft. ft.
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❑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. 8 ft. i• Brown Dirt
11/1/23 8 ft. 140 ft. Slate
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
James Oliviero ft. ft. Seams:51','57',62',75'=1g,92'=1g,
Facility/Owner Name Facility 1D0(if applicable) ft. ft. I 115-121'=4g, 125'=96g
4023 Yesteryears Ln., Marshville 28103 ft ft. •
Physical Address,City,and Zip 21.REMARKS
Union 02-164-008K •.
County Parcel Identification No.(PIN) .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/Iong is sufficient)
N q, DG�K � :reet— 11/10/23
• Signature Of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
with 1SA 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 ilNo 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 DNLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 140 (ft.) 24a. For All Wells: Submit this1 form within 30 days of completion of well
For multiple wells list all depths ifdiaerent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: 30 (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 Iniection Wells ONLY:p 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 i
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,IUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
100 Air 24c.For Water Supply&Injectio i 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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