GW1--01909_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: ,
John W. Huneycutt 14.WATER ZONES° " =I !7 ._
Y FROM TO DESCRIPTION
Well Contractor Name { . -'7---' {''-'7'.1 146 152 30 gpm
2465-A � ��_• ..v` �,� ft. ft.
NC Well Contractor Certification Number MAR 2 L 2024 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.icable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. jam ,,_,�:. <<,,�;_� ,,�, o ft 45 ft 61/8 •� SDR-21 PVC
. - - .^_... S"'-' 16.INNER CASING OR TUBING(geothermal closed-loop) -
Company Name D 0..t-31' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 23-276 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
R. ft. hi.
❑Agricultural ❑Municipal/Public
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.`GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑GroundwaterRemediation 19_SAND/GRAVEL PACK(ifapplica61e)•
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
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❑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,ha.dness.soil/rocktype,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft , Brown Dirt&Rock
4.Date Well(s)Completed: 1/1/24 Well 1D# 25 165 fL Slate
ft. ft.
5a.Well Location: ft. ft.
Paul Smith ft. ft. Seams:50',57',65',77',87', 132',
Facility/Owner Name Facility ID0(if applicable) ft R. 146'=30g
6025 RA Austin Rd, Marshville 28103 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 01-054-02
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field one lattlong is sufficient)
N Wgeli'L a) ›Waff,,ge.i.44-- 1/30/24
Si re of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15,4 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 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 of the
repair under 021 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: 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 INSTUCTTONS j '
9.Total well depth below land surface: 165 at.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
30 Division of Water Resorces,Information Processing Unit,
10.Static water level below top of casing: (f.) I.
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
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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
(gpm) 30 Air 24c.For Water Supply&Injection'Wells:
m 13a.Yield Method of test:
Also submit one copy of this fore within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to flue 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