GW1--05060_Well Construction - GW1_20230804

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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:
Dwight L. Huneycutt 14.WATERZONES
9 Y _ _ FROM TO DESCRIPTION
Well Contractor Name I`: (Ir.
E V 1- 414 it. 418 ft' I 1 quart per minute
4070-A AUG ft. fL
NC Well Contractor Certification Number !f 2 O23 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO- DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. kx4c;. ,,i ;gin ,r. L,r o ft. 45 ft- 6 1/8 SDR-21 PVC ,
Company Name [}ire �3.`;y 16.INNER CASING OR TUBING(geothermal closed-loop) .
23-141 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft: 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
fL ft. in.
:Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidentiat Water Supply(single) . ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 N• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring DRecovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. • ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.D_/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 DESCRIPTION(color.hardness.soil/rock type.grain size.etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Brown Dirt
6/3/23 Well #2 9 ft. 17 ft. Brown Rock
4.Date Well(s)Completed: Well 1D# ,
17 ft. 600 ft Slate
5a.Well Location: ft. ft.
Abagail Braswell H. ft.
Facility/Owner Name Facility 1Dil(if applicable)
9431 Indian Trail Fairview Rd, Indian Trail 28079 ft. Seams:53',79', 102', 123', 154',213',233',
tL B• 271,310',336',369',410',414'=1 qt per min
Physical Address,City,and Zip
21.REMARKS
Union 08225003E
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W a7)1G�L 171,4470,11e& 6/29/23
Signature Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 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.Ts this a repair to an existing well: ❑Yes or ElNo 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 ii21 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 O)VLYwith the same construction,you can
submit one form. SUBMITTAL TNSTUCTIONS
9.Total well depth below land surface: 600 (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 ft 100) construction to the following:
10.Static water level below top of casing: 30 (ft) 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 0'25 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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