GW1--02827_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD For Internal Use ONLY: E
This form can be used for single or multiple wells '
1.Well Contractor Information:
John W. Huneycutt FFRR WMATERZOO S DESCRIPTION
Well Contractor Name 105 0' 110 ft' I i 6 gpm
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2465-A ( ,_. . 7 ;a C';1j- 465 ft• 475 ft. I 9 gpm
t, `i t�.-L.i r 1 (forwells) (ifp )
NC Well Contractor Certification Number 7 I-- !� 15.OUTER CASING multi-eased OR LINER a livable
FROM _ TO DIAMETER THICKNESS MATERIAL
Well Drilling, Inc. MAY 0 C 2024 0 rt. 64 ft• 61/8 - in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Info:ricv:'i.i-1,7,-..r.,57Airtl, i'iFit FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Mir-IV-VV., ft. ft. 1 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.• (Agricultural ❑Municipal/Publicft
in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) • D. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 15.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. D.
❑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 size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft Brown Dirt
4.Date Well(s)Completed: 2/15/24 Well MO 50 60 c i Brown Granite
60 500 Blue Granite
5a.Well Location: ft. ft.
Kirk Davis ( it. n,
Seams:100', 105-110,_=6g, 115', 130', 170',
Facility/Owner Name Facility ID#(if applicable) ft. ft.
235,277,290,315,355,390,438,
900 Jim Kiser Rd., Concord 28025
n. R. 465'=9g
Physical Address,City,and Zip 21.REMARKS
Cabarrus j .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) �' l �(/
N Wge. a'• 1 / 3/15/24
Signs a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify 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 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: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(100) construction to the following:
10.Static water level below top of casing: 30 (D,) 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.) I 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i
• (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,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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. '
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013