GW1-2023-01419_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: +I
-14.WATERZONEs
John W. HuneCutt = i i
Y FROM TO DESCRn'TION
Well Contractor Name 151 & 160 It 11 15 gpm
2465-A _ _ ft. ft. I I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a linable
�` 5 �,T9 A n. FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 70 ft.
61/8 f � in• I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)' _
22-127 FROM TO DIAMETER THIC N"s MATERIAL.
2.Well Construction Permit#: In�c€Fie:` n PrlDn:3�?�y F�t:l',f g, R,
List all applicable well permits(i.e.County,State,Variance,1-oc' " ft. M
hL
3.Well Use(check well use): 17.SCREEN !
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL im
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) R' R•
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
oIrrigation Non-Water Supply Well: 0 fL 3 fL Bent.,Chips Gravity
❑Monitoring ❑Recovery 3 fL20 ft. Benttinite Pumped
Injection Well: il• %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM fL TO it. MA'EYJAL 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,hardnen soitfroek raid a etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 5 f. Red Dirt
4.Date Wells)Completed: 5/9/22 Well ID# 5 ft. 4,5 fL Brown Dirt
45 ft. 50 fL Brown Rock
So.well Location: 50 1185 tl. Blue Granite
Piedmont SFR, LLC ft. fL
Facility/Owner Name Facility ID#(if applicable)
5718 Sapp Rd., Rockwell 28138 f6 fL Seams:86', 125',151'=15gpm,165'
PP ft. fL
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)
N Rr zr' ({) 5/25/22
Signs of Certified Well Contractor i Date
6.Is(arc)the well(s): OPermanent 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 0No 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 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
S.Number ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
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 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: 21 Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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:
(Le.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(gum) 15 Method of test: Air
24c.For Water Supply&Injection iWells:
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. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013