GW1--01907_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Huneycutt 14.WATER ZONES I '
John W. HUne
Y FROM TO DESCRIPTION.
Well Contractor Name ,. 6'E•$ ,,y¢ F ` 280 ft• 290 ft 5 gpm
2465-A ft.
' ryryAA
NC Well Contractor Certification Number MAR 2 %� L G L5Y 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
FROM TO DIAMETER • THICKNESS MATERIAL
• Derry's Well Drilling, Inc..s,,,,,,,,,., ?,.,,.„,;,i, � ft'o 45 ft• 61/8 'in: SDR-21 PVC
Company Name [':;y .;a0{y i6,INNER CASING OR TUBING(geothermal closed-loop)
23-232 FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit-#: ft. ft. in:
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft ft. in.
. 3.Well Use(check well use): 17.SCREEN ; .
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
•
❑lndustrial/Commercial ❑Residential Water Supply(shared) ls•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft, 3 ft. Bent,Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 it Bentonite . Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. rt.
'❑Aquifer Test ❑Stormwater Drainage
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,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft• 20 ft. Brown Dirt
12/20/23 20 ft 340 it• Blue Rock
4,Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Chris Berger • ft• ft. Seams:50',65', 130', 175', 196',230',
Facility/Owner Name Facility ID#(if applicable) R ft, 250',280'=5g
339 Clontz Rd., Indian Trail 28079
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 08219006H
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) / )
N W G91uZ a). #apt.4ix 1/15/24
Sign e of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary 1
By signing this farm,I hereby certiy that,the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or ISA 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 -
' 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 I
submit one form. SUBMITTAL INSTUCTIONS ,
9.Total well depth below land surface: 340 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-WOO'and 2Qa 100' construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this,form within 30 days of completion of well
12.Well construction method: Rotary • construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: — 1636 Mail Service Center,Raleigh,NC 27699-1636
5 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013