GW1--01954_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD
For In[emal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
L. Huneycutt 14.WATER ZONES,
Dwight {
Y FROM TO DESCRIPTION I
Well Contractor Name 211 ft• 215 ft 3!gpm (237-240'=12 gpm)
4070-A 245 ft•. 250 ft 1 . 85 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap tirade)
FROM TO DIAMETER 1 , THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 50 ft- 6 1/8 in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2023-00022 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. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft it in.
❑Geothermal(Heating/Cooling Supply) g)Residential Water Supply(single) ft tt. in.
❑lndustrial/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 oRecovery 3 ft 20 ft- 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. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Red Clay
344.Date Well(s)Completed: 7/10/23 Well ID# 9 f‘ ft Brown Dirt
34 ft* 41 ft- . ' Brown Granite
5a.Well Location:
CodyConnell 41 f`• 250 f Blue Granite
ft. ft Seams:71',83', 112', 125', 188', 197',208'
Facility/Owner Name Facility IN/(if applicable)
ft ft. 211'=3g,237'=12g,245-250'=85g
3300 Greenbriar Rd., Concord 28025 ft. ft.
Physical Address,City,and Zip 21.REMARKS G- '^ ,^—,; ,--- „.
Cabarrus ; ' ' 'ts Lo L' i ' F-
County Parcel Identification No.(PIN)
MAN eOL�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ,
(if well field,one lat/long is sufficient) 1nEe;ri^ t^ 7
Gtr9
Signature of C fled Well Contractor Date
6.Is(are)the well(s): Permanent or OTemporary By signing this form,I hereby cert(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 ElNo 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
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: 250 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100) 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 Injection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i e.auger,rotary,cable,direct push etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: Air 24c.For Water Supply&Injection Wells:
• Also submit one copy of this forme 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