GW1-2022-10139_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1 `
Dwight L. Huneycutt FRO WA ZONES TO I DESCRIPTION
Well Contractor Name 156 fL 165 fL 1 j 20 gpm
4070-A rt. It.
NC Well Contractor Certification Number RECEIVED
�j V� 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICIflVESS MATERIAL
Derry's Well Drilling, Inc. NOV 0 ft• 146 IL 61/8 sDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothemraI closed-loop)
19-168 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Inje
ft. R. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
f4 ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OhTigation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 t` 20 fc Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: fr. 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 ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if mess
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,saiVrock type, eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 7 ft. Brown Dirt
2/26/22 7 f` 14 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
14 fc 185 ft- Slate
5a.Well Location: If. %
Thomas Bradshaw f4 ft.
Facility/Owner Name Facility ID#(if applicable)
550 Bear Creek Church Rd., Mt. Pleasant 28124 ft ft. Seams:as',53',60',79', 108', 115',
ft tL 156'=20gpm
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 lat/long is sufficient)
N W 3/15/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 01C.0100 or ISA 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.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back ofthis 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 22 (tt•) 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 Injection 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
13a.Yield(gpm) 20 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form'within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 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