GW1-2022-10144_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:
14.WATER ZONES
John W. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 88 ft• 95 fL 10 gpm
2465-A RECEIVED 107 fL 110 fL 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING for malti cased wells OR LINER if a Gcable
N O V O 0 FROM TO DIAMETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 �• 50 fL 16 1/8 " SDR-21 I PVC
Company Name ICAOI On PrOC"804()fly 16.INNER CASING OR TUBING 46othermal closed-loop)
18-19 THICKNESS FROM TO DIAMETER MATERIAL
2.Well Construction Permit#: fL 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
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) 9111esidential Water Supply(single) fL ft. m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 20 ft Bentonite Pumped
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK da, licable
TERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO fL MA
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,htudness soil/rock in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 15 ft. Brown Dirt
4.Date Well(s)Completed: 1/7/22 Well lD# 15 fL 29 ft. Brown Rock
29 ft• 185 ft• Blue Rode
5a.Well Location:
Billy Sowell tt ft.
Facility/Owner Name Facility ID#(if applicable)
4085 Dakeita Circle, Concord 28025 ft' fL Seams:67',66'=10gpm, 107'=5gpm
ft. 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 Geld,one laVlong is sufficient) '',,
N R, 9&16f- Li//l. �S/G�, ��t_ 1/30/22
Signs of Certified Well Contractor Date
6.Is(are)the well(s): 211'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No 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 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 Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.)
30 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 forth 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,Voticrground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13e.Yield(gpm) 15 Method of test: Air 24c.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
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