GW1--07504_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: .
14,,WATER-ZONES. i l t „
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 272 ft. 275 ft. I ' 6 gpm
4070-A ft. ft. 1
NC Well Contractor Certification Number -:1 r in 5.,OUTER CASING(foulti=rased wells)-OR LINER f f af, 'cable). _ _
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft• 61/8 in. SDR-21 PVC
Company Name /� 16:INNER CASINGOR TUBING(Reotliermal closed loop)
SE2022-001ao •
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit It: ft. ft. in.
List all applicable well permits(i.e.County.State,Variance,Injection,etc) ft.
in.
3.Well Use(check well use): n17.'SCREEN ,: _ -.
Water Supply Well: FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
H. ft. is,
❑Agricultural ❑Municipal/Public '
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. is''m',
0 Industrial/Commercial ❑Residential Water Supply(shared) 48..GROUT ,- °r ._
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 R• 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring (]Recovery 3 ft. 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation T19:SAND/GRAVELPACK(if applicable) = = =` ,7
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. 1
oExperimental Technology OSubsidence Control
-20 DRILLING LOG(attach additional sheets If Decimally)'== ._:-.
❑Geothermal(Closed Loop) ❑Tracer FROM TO. DESCRIPTION(color,hardness,soil/rod(type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 17 ft• i, Brown Dirt
3/16/23 17 ft• 26 ft. i' ' Brown Rock
4.Date Well(s)Completed: Well ID#
26 n• 345 ft• ' Slate
5a.Well Location: ft, ft.
Lisa&Brandon Bumette
ft• ft• Seams: 124', 186',216',272-275'=6gpm
Facility/Owner Name Facility ID#(if applicable) ft.
6511 Mt. Pleasant Rd S, Concord 28025 ft. ft.
4 4 ',Physical Address,City,and Zip '
21 REMARKS---> _ .. _� - - :�,,, `�.,�, ,1],..-
Cabarrus NOV 9 11 2021
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DV:. _ 6J�''-2 6`
• (if well field,one lattlong is sufficient)
�lti L 7
N R, 4/15/23
Signature o ertified Well Contractor i' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thatthe 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 EINo 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 1
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
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: 345 (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@100) construction to the following:
i
10.Static water level below top of casing:
30 (it.) 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 (jn.) 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 ,
(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) 6 Method of test: Air
24c.For Water Supply&Injection;Wells:
Also submit one copy of this form within 30 days of completion of
Granularwell construction to the county liealth department of the county where
13b.Disinfection type: Amount: 1/2 Ib.
constructed. j
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water'Resources Revised August 2013