GW1--01961_Well Construction - GW1_20240325

i
WELL CONSTRUCTION RECORD For Internal Use ONLY: t
This form can be used for single or multiple wells
1.Well Contractor Information:
L. Huneycutt 14.WATER ZONES .. I • '
DwightY FROM TO DESCRIPTION 1
Well Contractor Name 95 rt. 98 ft. I ; 3 gpm
4070-A 210 ft 220 ft- j. 9 gpm •
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I, TIDCICNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 47 ft. 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-154 FROM TO DIAMETER 1" 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
ft. ft. in. .
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) tt ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 u 3 ft 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)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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 421 Remarks) 0 ft- 26 ft Brown Dirt
12/30/22 26 ft- 37 ft Brown Rock
4.Date Well(s)Completed: Well ID# 37 ft- 245 ft- ; Blue Granite
5a.Well Location: ft. ft.
Steven Stewart
Facility/Owner Name Facility UN(if applicable) ft. R' Seams:'95-98'=3g,112', 154', 191-196',
ft. ft. 210'9g
2950 N. Lentz Harness Shop Rd., Mt. Pleasant 28124 ft. ft. ..
Physical Address,City,and Zip
Ys P 2L REDfARKS' �L,_C ``_�;, f'ice"'
Cabarrus —�"_' 'V 9; t��
County Parcel Identification No.(PIN) lyiAi' G L� 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: IR �'r; /°F
(if well field,one lat/long is sufficient)
i7 a r(;•^,. �,t �
#�v'0' Q/45/231 ..
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify 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 ENo 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
submit one form SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: 245 (ft) 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:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: hi'addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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
P
12 AU 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