GW1--01962_Well Construction - GW1_20240325

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
14.WATER ZONES
John W. Huneycutt
FROM TO DESCRIPTIONI
Well Contractor Name 260 ft- 265 ft- I t 1 gpm
2465-A 280 ft 285 ft- I ' 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable)
FROM 'TO DIAMETER '• THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft 61/8 'i SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2023-00163 FROM TO DIAMETER i THICKNESS MATERIAL •
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. DI-
3.Well Use(check well use): 17.SCREEN ,
Water Supply Well: • FROM TO DIAMETER SLOT SIZE TIHCICNESS MATERIAL
❑Agricultural OMunicipal/Public ft H. in.
❑Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft ft in.
❑Industrial/Cornmercial ❑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 t 20 f Bentonite' ' Pumped
Injection Well: ft. ft.
•
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM • TO MATERIAL ' EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStormwater 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- 12 ft. Brown Dirt
1/23/24 12 ft 30 it . Brown Rock
4.Date Well(s)Completed: Well ID# 30 ft 300 ft Blue Rock
5a.Well Location: ft. ft '
Michael&Lisa Flaherty ft ft Seams:87', 116', 125',200',
Facility/Owner Name Facility ID#(if applicable)
7149 Kluttz Rd., Rockwell 28138 ft. ft 260'=1g,280'=4g
ft ft.
Physical Address,City,and Zip _
21.REMARKS 1.,.%• :a ?1 p 7--
Cabarrus y b -�...4/i....; aj L)
County Parcel Identification No.(PIN) 'MAR p C` 70N
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification /
(if well field,one lat/long is sufficient) �// �r ar_ t
l YY inY�iii�i+iii mil ,..,�:,pv^i„t,•'.es7 Vh.�^
(//t(.2 1 3, d2/15/24
N W .':'J4'
Si of Certified Well Contractor Date
6.Is(are)the well(s): i2lPermanent or DTemporary By signing this form,I hereby cert fy 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 ]No 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 1
9.Total well depth below land surface: 300 (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@I00) construction to the following:
it
10.Static water level below top of casing: 30 (fL) 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
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: 1
(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,ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Injection 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