GW1-2022-10146_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: k
Dwight L. Huneycutt FRO ATER ZONES TO DESCRIPTION`
Well Contractor Name 195 "' 205 ft j 7 gpm
4070-A [�}��D ft. ft.
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NC Well Contractor Certification Number C 15.OUTER CASING for mutti-cased wells OR LINER if a liable
FROM TO DIAMETER I 1IDC[aIESS MATERIAL
Derry's Well Drilling, Inc. NOV 1 O 2022 0 ft- 44 fA 6 1/8 '° SDR-21 I PVC
Company Name 16.INNER CAStG OR TUBING eothermal closed-loop)
N/A II a'1 Pf'sCtl�4 Utk FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit th f klRff ft ft in-
List all applicable well permits(1.e.County,State,Variance,Injection,etc)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Weill: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft ft in.
gAgricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft• 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neces
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrack rain sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 fr. Red Clay
5/26/22 14 ft. 285 ft. Blue Granite
4.Date Well(s)Completed: Well ID# ft ft.
Sa.Well Location: M ft.
Perry Troutman It. ft
Facility/Owner Name Facility ID#(if applicable) It.
Seams:58',69', 130', 136', 195'=7g
16156 Glenmore Rd., Gold Hill 28071
fL ft.
Physical Address,City,and Zip 21.REDIARKS
Cabarrus
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 5/5/22
Signature of 'fled Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)construcied in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofihis 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 421 remarks section or on the back ofihis 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: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 36 (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 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 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.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 27699-16M
13a.Yield(gpm) 7 Method of test: Air
24c.For Water Supply At 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