GW1--05044_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 554 ft• 559 ft 3 gpm
2465-A ft ft
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if sip licaWe)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft6 1/8 ' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-11 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. to.
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
fL ft. is
❑Agricultural ❑MunicipaUPublic _ _
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑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. 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,sail/rock type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 ft Brown Dirt
2/20/24 15 ft 580 ft. Slate
4.Date Well(s)Completed: Well ID8 ft. ft.
5a.Well Location: ft. ft.
Jema Builders, LLC ft. ft
Seams:50, 107, 167,231 ,270,280,
Facility/Owner Name Facility IDII(if applicable) ft. ft
1038 Heath Helms Rd., Monroe 28110 (Brief Est.-Lt8) 298',336',354',a1o'�a�9',55a'=3g,
ft.
Physical Address,City,and Zip 21.REMARKS
Union 08087001W AUG 0 624
County Parcel Identification No.(PIN)
' t', -;:.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l i"' - .. ,
(if well field,one let/long is sufficient)
22.Certification: / (_,;,
N W g
�diL a . 3/18/24
Si a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I 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 ONo 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: 580 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 1@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 Injection Wells ONLY: In 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:
(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) 3 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