GW1--05038_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:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name :+- i "�N } a .1 ,L 52 ft. 55 ft 2.gpm (90-95'=2gpm)
' 2465-A , - i �i t,. ?..t 130 ft 140 ft 2
9pm (192-198'=9gpm)
NC Well Contractor Certification Number A U U 0 ' 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,r, fl�,,r.-cvs y;a l Ur,ii 0 ft 49 ft. 6 1/8 in• SDR-21 PVC
l fst ;,
Company Name DV '30.;23 16.INNER CASING OR TUBING(geothermal closed-loop)
22-350 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.
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) it ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROMi TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent Chips Gravity
Non-Water Supply Well:
❑Monitoring ORecovery 3 ft 20 ft Bentonite Pumped •
Injection Well: ft. t.
:Aquifer Recharge ❑Groundwater Remediation , 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier 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,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 . ft Brown Dirt
2/21/23 ` 25 ft• 200 ft Slate
4.Date Well(s)Completed: Well ID# . ft • ft.
5a.Well Location: ft. ft.
Taylor Thomas ft. ft. ,
Seams:52'=2gpm,75',90'=2gpm,
Facility/Owner Name Facility ID//(if applicable)
7230 Fish Rd, Marshville 28103 ft ft. 100', 13o'=2gpm, 150', 192'=9gpm
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 01-015-001 B
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 Wk1 - W. rdt- 3/15/23
Sign of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby cent fy that the well(X)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 EJNo 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 1121 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: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (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 infection Wells ONLY: In addition to sending the form to the address in
Rta 24a above, also submit a copy of this form within 30 days of completion of well
o
12.Well construction method: ry construction to the following:
(Le.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) 15 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