GW1--07507_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 �DESCRIPTION
FROM TO DESCRIPTION
Well Contractor Name 352 ft• 355 ft• I 3 gpm
4070-A 450 ft• 455 ft• 1 47 gpm
NC Well Contractor Certification Number
b151 OUTER CASING(foe malts-cased wells)UR I INER(if epphcabie) ,2
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 62 ft• 6 1/8 ! i>.. SDR-21 PVC
Company Name '16JNNER.CASINGO&TUBING(geothermal closed-lanp)= _
21-302 FROM TO DIAMETER THICKNESS MATERIAL
IWell 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): i7.=SCREEN 5 .s _
Water Supply Well: FROM TO DIAMETER , SLOT SIZE _ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ft ft in'
❑Industrial/Commercial ❑Residential Water Supply(shared) 's 18:GROUT< ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ORecovery 3 fa 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation =19rSAND/GRe1VF.L PAC&(if a'pplieatilc) _ i...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAMFN METHOD
ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control 20._DRILLINGLOG(attach'additional sheets if necessary) _ W, t _
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,eoa/rocktype,groin eke,etc.)
❑Geothermal(Heating/Cooling Return) pother(explain under#21 Remarks) 0 it 38 ft• Brown Sandy Dirt
4.Date WeU(s)Completed: 4/24/23 Well ID# 38 ft• 51 ft• Junky Rock
51 ft. 465 ft• t Blue Granite
5a.Well Location: ft. ft.
Tron Properties ft. ft• Seams:74',91',116', 185',238',332',
Facility/Owner Name Facility ILO(if applicable) ft. ft. 350',352'=3gpm,450-455'=47gpm
9625 Reedy Ln., Harrisburg 28027 fr. ft.
Physical Address,City,and Zip '121 REMARKS -. i s-- �.,_ :
Cabarrus -T T ,-
y} �'County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: N IJ V 1 0 Z0Z3
(if well field,one lat/long is sufficient) 1
N W D`%t�� I. / Ar.'viai.:_-.`,,2 45] U/y/G/r,3=":7 r,7 1 JIIN Signature of Certified Well Contractor ! Die-.—`-
6.Is(are)the well(s): t7Permanent 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: DYes or EJNo 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#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*loch 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: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-S@200'and 2@,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) 50 Method of test: Air 24e.For Water Supply&Injection Wefts:
Also submit one copy of this foiml 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