GW1-2022-10148_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:
John W. Huneycutt 14.WATER ZONES
FROM TO I DFSCRIPTH)N
Well Contractor Name 80 ft 103 ft
3gpm
2465-A 190 fL 193 ft ! 2 gpm
NC Well Contractor Certification Number N 0 V`' 0 2022 15.OUTER CASING(for multi cased wells OR LINER if a licable
FROM TO DG►METERi THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,junfivo1 n PL UM 0 ft. 58 ft- 6 1/8 ii" I SDR-21 I PVC
Company Name DWQMKM 16.INNER CASING OR TUBING fecothermal closed-loo
17-307 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL in.
List all applicable well permits(i.e.County,State,Variance,[ejection,etc.)
f4 it. lin.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. i.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 fL 20 ft- BentonitePumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)FROM TO
❑Aquifer Storage and Recovery ❑Salinity Barrier it. it MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. R
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color hardn soll/mck s' ero
[]Geothermaleating/Cooling Return ❑Other(explain under#21 Remarks 0 ft 12 ft Brown Dirt
4.Date Well(s)Completed: 1/10/22 Well ID# 12 ft 36 rt Brown Rock
36 R• 205 it Blue Rock
Sa.Well Location: ft. R
Joe Wadlinger [t. ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams: s5,$0'-103'=3g, 178',
13481 Bethel Ave. Ext., Midland 28107 '
rt rt- 190'=2g, 195'
Physical Address,City,and Zip 21.REMARKS
Cabarrus
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 1/25/22
SignKre of 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 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 421 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to;provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Far 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: 205 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: Waddition 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) 5 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