GW1--01958_Well Construction - GW1_20240325

I,
WELL CONSTRUCTION RECORD For Internal Use ONLY: !'
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14. -i .
9 Y FROM TO DESCRIPTION
Well Contractor Name 430 ft 440 it - I I 30 gpm
4070-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 44 ft 61/8 :in: PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2023-00148 FROM TO DIAMETER in. THICKNESS MATERIAL
2.Well Construction Permit#: ft ft.
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
ft ft in.
❑Agricultural OMunicipal/Public
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft.
Olndustrial/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:
OMonitoring ❑Recovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL i EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test OStormwater Drainage
ft. ft.
❑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.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 17 ft Brown Dirt
12/5/23 18 ft 440 ft Slate
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft ft
Cassie L. Measimer
ft. ft Searits:49',55',77', 108', 119', 133',
- Facility/Owner Name Facility ID#(if applicable)
14665 Short Cut Rd, Gold Hill 28071 ft 430'=30 gpm
ft ft
Physical Address,City,and Zip 21.REMARKS ' ''l''-''.
Cabarrus , '� .c-d'L..: vV1
County Parcel Identification No.(PIN) MAN ,`
2
20,4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ,
(if well field,one lat/long is sufficient) Ink..i .,%?.-,n?fr...n. °R 5I t tpRo
N w Dt•U� �^ Y+ JGL;12137/23
Signature Certified Well Contractor Date
6.Is(are)the well(s): 171Permanent or ❑Temporary By signing this form,I hereby certif.,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: [Wes or I]No 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 1
9.Total well depth below land surface: 440 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdeerent(example-3Q200'and 2Q100') construction to the following:
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 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: i�/ construction to the following: i' '
(i.e.anger,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
ii
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount 1/2 Ib, well construction to the county health department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resoilaces Revised August 2013
1