GW1--05053_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 1 .WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 73 ft 88 ft• 4 gpm
2465-A 145 ft• 150 it 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap tieaWe)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 51 ft• 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-325 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft 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. rt. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
DMonitoring ❑Recovery 3 ft. 20 itBentonitei 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,soiurock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)._ 0 ft. 25 rt. Brown Dirt
5/21/24 25 ft• 305 ft Slate
4.Date Well(s)Completed: Well ID# ft. ft ._
5a.Well Location: ft. ft. . "-' .
Christian Carpenter n rt. Seams:55',73-88'=4g,96', 110',
Facility/Owner Name Facility 1Db(if applicable)
ft ft. 145-150'=2g,235'
4044 Yesteryears Ln., Marshville 28103 ff. ft {
Physical Address,City,and Zip �' '
21.REMARKS 4• • • �,,.i
Union 01-160-002A AUG J g ��
County Parcel Identification Na(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1 r,f3`''= -;•+"s••..:.,u
(if well field,one lat/long is sufficient) �y 17 C: •• s
ILIf/ a Yr rd t f�',6/15 2
N W 6/15/24
Signa of Certified Well Contractor Date
6.Is(are)the well(s): lZPermanent or ❑Temporary 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
S.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: 305 (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@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 Mail 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) 6 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