GW1--01957_Well Construction - GW1_20240325

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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 f :
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 105 ft- 110 ft 2 gpm (130-133'=3gpm)
4070-A 152 ft- 155 ft- 10 gpm (195-205'=15gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I ', THICKNESS MATERIAL
Derry's Well Drilling, Inc. o f- 44 f- 6 1/8 .. , SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2023-00030 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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geotheal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.rm
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 f- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 27 ft Brown Dirt
4.Date Well(s)Completed: 9/18/23 Well ID# 27 ft- 225 ft. Slate
ft. ft. I•
5a.Well Location: ft. ft ' '
Lance Ferris
ft. ft. Seams:48',53',95',99', 105'=2g,
Facility/Owner Name Facility ID#(if applicable) ft. rt. 130'=3g,152'=10g, 195'=15g
1381 Trotter Circle, Mt. Pleasant 28124 ft ft.
Physical Address,City,and Zip �.
21.REMARKS .
tie„_-6 w '�.
Cabarrus ; I '� .,-ii ',./^''.
County Parcel Identification No.(PIN) MN n .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1f1,+i 2 ���q
(if well field,one lat/long is sufficient) �G4JtL. "
N W ''Q/;sot* .+a
Signature of Certified Well Contractor I Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby cert fy 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 DNo copy of this record has been provided to the Well owner.
If this is a repair,fill out known well construction ttrformation 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdijferent(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
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11.Borehole diameter: 6 (in.) 24b.For Infection 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: I
(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) 30 Method of test: Air
24c.For Water Supply&Infection Wells:
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
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