GW1--05047_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 278 ft. 282 ft- 1 gpm
2465-A 445 ft- 450 ft 1 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 irk SDR-21 PVC
Company Name 14 INNER CASING OR TUBING(geothermal closed-loop)
23-12 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM18GROUT 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
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain eat,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 20 ft- Brown Dirt&Rock
3/2/24 20 f 465 Slate
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Jema Builders, LLC
ft- ft. Seams:50',70', 77',92,105, 125, 130, 150
Facility/Owner Name Facility 113k(if applicable)
1022 Heath Helms Rd., Monroe 28110 (Brief Est.-Lt4) rt. ft. 190',270',27 ft. ft. 445'=1 g'lg 310',381',
Physical Address,City,and Zip 21.REMARKS -
Union 08087001R s...... ... ;.-.,...
County Parcel Identification No.(PiN) (�A'I G 0 674
?4
A
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: !1
(if well field,one let/long is sufficient)
—'1'..
N W 3/28L24 _
Si: :;l of Certified Well Contractor Date
6.is(are)the well(s): OPennanent or DTemporary 11y signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/SA NCAC 02C'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IDNo 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 s21 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: 465 (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple welts list al/depths ifdifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing 30 cm) Division of Water Resources,information Processing Unit,
If water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
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
2 Air 24c.For Water Supply&injection Wells:
13a.Yield(gpm) Method of test: 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