GW1--01955_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 DESCRIPTION
Well Contractor Name 72 ft 74 ft- 1 gpm (167-172'=3gpm)
2465-A 285 ft. 290 ft- 4 gpm (306-315'=92gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO DIAMETER I. THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 46 f4 61/8 ' , SDR-21 PVC
•
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2022-00053 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
DAgricultural ❑Municipal/Public H. Ft. in.
❑Geothermal(Heating/Cooling Supply) (]Residential Water Supply(single) it. ft. in.
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❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fc 3 f6 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. ft. ,
DAquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL'', EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary) ,
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 40 ft- Brown Dirt&Rock
4.Date Well(s)Completed: 8/31/23 Well ID# 40 ft 325 ft ;; Slate
ft. ft.
Sa.Well Location: R. ft.
Edward Stephen Moose ft. ft. Seams:51',72'=1g,111', 125', 141',
Facility/Owner Name Facility ID#(if applicable) ft. ft 167'=3g,230',271',285'=4g,306'=92g
949 S. Lentz Harness Shop Rd, Mt. Pleasant ft. ft.
Physical Address,City,and Zip 21.REMARKS ' <-„�'` '>w i, i°"' '
Cabarrus :" ''L•- o� h
County Parcel Identification No.(PIN) MaR,2 �e 202
UC`F
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(dwell field,one lat/long is sufficient) Li,
W in,—i, :i:l Prr . f1.7 E,t
r � 71'f,'
N W9/15/23
Si of Certified Well Contractor Date
6.Is(are)the well(s): CdPernianent or OTemporary By signing this form,i hereby certfy that:the wells)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or I SA 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 we!!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: 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft,) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I.
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 WELTS 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 fora%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