GW1-2022-10032_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells S
1.Well Contractor Information: `
14.
FROM
Dwight L. Huneycutt FROM
I
FROM TO DESCRIPTION I I
Well Contractor Name 298 fk 300 f• 1 gpm
4070-A �f 386 ft 390 ft. ! i 19pm
nI
NC Well Contractor Certification Number NOV• 0 7 202Z 15.OUTER CASING for multi-cased wells OR LINER if n licable
FROM TO DIAMETER THICKNESS I1rATElifAL
Derry's Well Drilling, Inc. r ,Gym i�1 Prt>G?Je^,�pri Ur�A 0 ft 60 ft 61/8 is ,' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22-69 FROM TO DIAMETER 77IICIINFSS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(i.e.Coun(K State,Variance,Injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
ft. ft. is i
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 23Residential Water Supply(single) ft. % in.
❑Industrial/Commercial ❑kesidential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
[]Monitoring ❑Recovery 3 20 f` 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 ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer' FROM TO DFSCRIMYON color,hardness,soil/mck type,grain site,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 16 ft. Brown Dirt
4/21/22 16 ft. 22 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
22 f`• 465 ft• Slate
Sa.Well Location: ft. ft.
Mario Maciel ft: ft.
Facility/Owner Name Facility ID#(if applicable)
It. ft. Seams:75', 110', 136,157',255',298'=1g,
9105 Jack Connell Rd., Indian Trail, 28079
ft. ft. 380%386=1g,430'
Physical Address,City,and Zip 21.REMARKS
Union 08216009
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Wong is sufficient)
N �, 4/30/22
Signature of citified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 0No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain Cite nature ofthe
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 fornL SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 465 (m) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths ifdijferent(example-3 200 and 2@100) construction to the following:
10.Static water level below top of casing: 43 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Cinter,Raleigh,NC 27699-1617
11.Borehole diameter;
6 (in.) 24b.For Iniection 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 Rotary 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
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&LDjection Wells:
Also submit one copy of this form 1within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county It ill department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resourcesi Revised August 2013