GW1--05042_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD 'For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 468 ft- 475 ft. 2 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o fL 47 'L 61/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-359 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit II: ft. ft. in.
List all applicable well permits Be.County,State,Variance,Injection,etc.)
ft. fL 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) ]Residential Water Supply(single) rt. rt. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 n. 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)
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) OTracer FROM TO DESCRIPTION(color,hardness,sal/rock type,grain sine,etc.)
DGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 f• Brown Dirt&Rock
4.Date Well(s)Completed: 3/28/24 Well ID= 25 ft. 500 ft. Slate
ft. R
Sa.Well Location: ft. R. __ .
Michael Clontz ft.
Seams:52',60',70',75', 107', 125', 157',
Facility/Owner Name Facility IN((if applicable)
ft.3007 Camden Rd., Marshville 28103 "` 176', 190',205',220',230',270',315',
ft. ft. 380',390',440',468'=2g
Physical Address,City,and Zip 21.REMARKS i . '
Union 06-111-005M -
County Parcel Identification No.(PIN) _ AUGt) 0 �!2 4
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 11 L U Ct. i
(dwell field,one lat/long is sufficient)
N W EAL r f ldt ;r,:4/14/2-i4;. ,.. ! _ a `%r.
Si ure of Certified Well Contractor Date
6.Is(are)the well(s): (Permanent or ❑Temporary By signing this form,I hereby certtify 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 UNo 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 ifdi$erent(example-3@200'and 2(41100') 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
II.Borehole diameter: 6 (in.) 24b.For Infection 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013