GW1--05045_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 454 ft. 458 ft. 2 gpm
2465-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Beside)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft- 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-03 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ti: ft. rt. 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
H. ft in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: —
❑Monitoring ❑Recovery 3 fL 20 iL Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier ft. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft
DExperimental Technology ❑Subsidence Control _
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sine,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 fL Brown Dirt&Rock
4.Date Well(s)Completed: 2/23/24 Well ID# 15 600 tt. Slate
ft. ft.
5a.Well Location: ft ft
Jema Builders, LLC
ft. ft. Seams:70',90',95', 103', 135',265',
Facility/Owner Name Facility IDk(if applicable)
1030 Heath Helms Rd., Monroe 28110 (Brief Est.-Lt6) ft. ft. 295',310',336',454'=2g,570'
ft ft. .
Physical Address,City,and Zip 21.REMARKS : .... •..t 6... . ./ i....
Union 08087001U ,�({;
County Parcel Identification No.(PIN) AUG J 0CtlZ4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Ir.'.:.:" - -. -':'
(if well field,one lat/long is sufficient) 22.Certification: ll 1;...,,, �-
N Wi!L a/. 3/18/24
Signs 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 I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an ezisting well: ❑Yes or EINo 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 421 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: 600 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdii ferent(example-3@200'and 2@l00) 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 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013