GW1-2021-00006_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt 14,WATERZONEs
John W. -
FROM TO DESCRIPTION
Well Contractor Name 174 ft' 180 & 20 gpm
2465-A ft ft.
NC Well Contractor Certification Number 15t OUTER CASING for multi rased wells OR LINER trap livable
FROM TO DIAMETER Mims I MATERIAL
Derry's Well Drilling, Inc. 0 ft 46 ft- 61/8 iti1 SDR-21 I PVC
Company Name 16.`INNER CAStNG.OR TUBING(geothermal closed-loop)
FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: N/A 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
ft ft in.
❑+Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOONT
❑Irrl ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 rt. 35 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if aimlicabli
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft MATERIAL EMPLACEMENT METHOD
❑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 soil/mck type in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 7 ft. Brown Dirt
6/9/21 7 ft' 18 ft. Brown Rock
4.Date Wells)Completed: Well II)#
18 ft• 200 ft Blue Rock
5a.Well Location: ft. ft
Eddie Moose tt. ft
Facility/Owner Name Facility ID#(if applicable)
rt ft. Seams:65', 110', 124', 1 6X C1 7442pa
Bear Creek Church Rd., Mt. Pleasant 28124 tt ft
Physical Address,City,and Zip
21.REMARKS ` _ ._'
Cabarrus
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) g��
,,'' //N �, W. �l,CIL4tiA 6/30/21
Sig4&e 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 END 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
S.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 oneform. 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 ifdierent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 21 (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.) 24b.For Infection 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 20 Method of test: Air 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