GW1--07506_Well Construction - GW1_20231120

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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:
14.WATER ZONES ., '.. •- _ -
Dwight L. Huneycutt T 1,
9 y FROM TO DESCRIPTION
Well Contractor Name 116 fi• 121 fi• 1 5 gpm
4070-A ft. ft. 1
NC Well Contractor Certification Number 715.OUTER"CASING(forinultr-cased wells)ORI INER(if aplicable)--
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 48 ft• 6 1/8 I in, SDR-21 PVC
Company Name '°.16.INNER CASING ORT(IBING(gentilermalcloind-loop) `;
CHA-WE-2022-00045 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. I in.
ft.
3.Well Use(check well use): =17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. .
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft' ft' 'n
❑Industrial/Commercial ❑Residential Water Supply(shared) iS,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
❑Irrigation 0 fA 3 ft' Bent.Chips Gravity
Nun-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 fi• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SANINGRAVELYACK(if applicable) _ _ . ._ . {f a. > x
FROM TO' MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier, ft- ft. i
❑Aquifer Test ❑StormwaterDrainage ft ft-
❑Experimental Technology OSubsidence Control •20:DRII LINGrLOG(ettach additional Sheets-if itecessaty)
s
❑Geothermal(Closed Loop) ❑Tracer FROM -TO DESCRIPTION(rotor,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 18 ft• i Brown Dirt
5/8/23 18 fi• 28 ft• Brown Rock
4.Date Well(s)Completed: Well ID#
28 ft. 300 . to Slate
5a.Well Location: (f, ft.
Nathan Yost
ft. it. Seams:72',116-121'=5gpm, 125', 133',
Facility/Owner Name Facility ID#(if applicable)
ft. _ ft. i 172'
7219 Timothy Dr., Concord 28025 (Lot 35) ft.
Physical Address,City,and Zip .fZl:REMARKS „..:= . � . . '.;.,1''.:......:,. _._�_ __.r.. .-p - r�..;` "x, ..
Cabarrus t't �-- .7." `r q� -•)
County Parcel Identification No.(PIN) Y lJ V 0 2U23
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllongissufficient)
22.CertiTication: 1n5:.1,, .�`r..- ,
Gti�x1 / i1r,:
N W
�—` �'I'r`5/20/23
Signature of Certified Well Contractor , Date
6.Is(are)the well(s): 127Permanent or OTemporary 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 ONo 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 I.
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 of wells constructed: ' - 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: 300 (ft.) 24a. For All Wells: Submit this i form within 30 days of completion of well
Far multiple wells list all depths if different(example-3(a)200'and 2@100) construction to the following:
30 Division of Water Resources,Information Processing Unit,
(ft.)
10.Static water level below top of casing:
If water level is above casing,use"+" 1617 Mall Service Center,nter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: I 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: 1
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,jUnderground Injection Control Program,
'FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 5 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Granular Amount: /2 Ib. 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