GW1--05037_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:
-* e •.. 14.WATER ZONES
John W. Huneycutt + j
t_,a "e ,J FROM TO DFSCRD'TION
Well Contractor Name - 222 190 ft 195 ft 5 gpm
2465-A AUG 0 2023 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
tnic.r r.Y)Cr1 I r: V j-4,.'',g Ura FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. Dwo.inoi3 o ft 54 ft 6 1/8 i"- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22-389 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C7 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.
0 Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft in
❑Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 n• 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 ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 16 ft. Brown Dirt
4.Date Well(s)Completed: 3/18/23 Well ID# 16 ft 25 ft Brown Rock
25 ft 325 ft Slate
5a.Well Location: ft. ft.
Stewart Marsh
ft ft Seams:75',92',97', 190-195'=5gpm,
Facility/Owner Name Facility ID#(if applicable) ft ft. 235',240'
9803 Olive Branch Rd, Marshville 28103 ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 01-066-004(portion of)
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/long is sufficient) /
N Wgd/T a). 7/7e.a7r-zzet-
4/10/23
SignOfte of Certified 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)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 BNo 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: 325 (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@100) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 45 (ft.)
If water level is above casing,use"+" 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:
(ie.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.
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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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