GW1-2023-01425_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DerryDerr` L. Huneycutt 14.WATER ZONES . . .,
Y FROM ' TO I DESCRIPTION
Well Contractor Name y'• ' '': 288 ft 293 it• I I 7 gpm
2663-A ,t r�
ft. It-
NC Well Contractor Certification Number �p Q Z�23 15.OUTER CASING for multi-cased wells OR LINER if a licable
DD J FROM TO DIAMETER 1 TmCIQIESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 46 . ft I 61/8 j SDR-21 PVC
Company Name lily+'+3Y ^'u ° 16.INNER CASING OR TUBING eothermal closed-loo -
22-189 � � OG FROM TO DIAME GS TER • THICKNS MATERIAL
2.Well Construction Permit#: ft ft. i' 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
❑Agricultural ❑MunicipaLTublic It. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. ML
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni ation 0 it .3 ft Bent Chips Gravity
Non-Water Supply Well: 3 ft 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK if applicable)
[]Aquifer
TO MATERIAL EMPLACEMENT METHODAquifer Storage and Recovery ❑Salinity Barrier tt ft I
❑Aquifer Test ❑Stormwater Drainage
ft ft f
❑Experimental Technology ❑Subsidence Control -
-20.DRII LING LOG attach additionai'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,w Unck type,grain si m,etc
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under#21 Remarks) 0 ft 25 ft Brown Dirt&Rock
4.Date Well(s)Completed: 11/22/22 Well ID# 25 ft 365 ft Blue Rock
ft. ft
Sa.Well Location: ft ft
Mario&Cambrian Labrador
Facility/Owner Name Facility ID#(if applicable) f t fr' Seams:56',68-89,98', 108', 116', 133',
2800 Biggers Rd., Concord-28025 ft ft.
194',;225',247,270';288-293'=7gpm,
t.
j 320',328,340'
Physical Address,City,and Zip -2L REMARKS
Cabarrus
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one laUlong is sufficient)
N W 'F� 12/1/22
Signature of�Ce fled Well Contractor Date
6.Is(are)theweil(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thdt,the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has beeir provided to the well owner.
If this is a repair,fill out known well construction information and explain the enure of the
repair under#21 remarks section or on the back ofthis form 23.,Site diagram or additional well details:
You may use the back of this page 6 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: 365 (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: 32 A) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Cetiter,Raleigh,NC 27699-1617
11.Borehole diameter, 6 (in,) 24b.For Iniection 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection C.ontral Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(glint)7 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: 1/2 lb• well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resn-i Revised August 2013
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