GW1--05163_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FROM
TO DESCRIPTION
Well Contractor Name 135 ft. 140 ft. 6gpm
4070-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for meld-eased wells)OR LINER(if a limbic)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 a. 82 ft• 6 1/8 it- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
10012710 FROM TO DIAMETER_ THICKNESS _ MATERIAL
2.Well Construction Permit#: ft R. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
ft. ft. Ti
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft• Bent.Chips Gravity
Non-Water Supply Well: H
❑Monitoring ❑Recovery 3 20 ft Bentonite Pumped
Injection Well: it It
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
tt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional Iamb if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,pain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it• 66 ft. Brown Dirt
1/4/24 66 ft• 75 ft• Brown Granite
4.Date Well(s)Completed: Well MN
75 et. 245 ft• Blue Granite
5a.Well Location: it ft.
John Anaukumar
ft.
L Seams:89',95', 135%=6g
Facility/Owner Name Facility IDk(if applicable)
ft. ft.
429 Trafalgar PI., Matthews 28105 �.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 213-024-17 AUG 0 Z624
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ir° _ v.3 ter'«
(if well field,one lat/long is sufficient)
N W
PC,ti�%�.�. �u�t c��[L�L` 2/2/24
Signature of ertified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 ElNo 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: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
1-'or multiple wells list all depths if different(example-3@,200'and 4)100') construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'*" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24h For Iniection 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:
(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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 6 Method of test:
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