GW1--05055_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:
L. Huneycutt 14.WATER ZONES
Dwight
Y FROM TO DESCRIPTION
Well Contractor Name 63 ft• 66 ft 3 gpm (75-80'=3 gpm)
4070-A 190 ft• 195 fL 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 45 f• 61/8 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
24-78 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. ill.
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
fL ft. in.
❑Agricultural ❑Municipal/Public ,
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in.
❑industriaVCommercial ❑Residential Water Supply(shared) IS. ROUT
FROMG 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,soil/rock type,pain use,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Brown Dirt
4.Date Well(s)Completed: 6/13/24 Well ID# 9 f- 28 ft. Junky Brown Rock
28 rt 265 ft• Slate
5a.Well Location: ft R.
Emerald Pointe
ft. ft. Seams:58',63'=3g,75'=3g, 190'=2g
Facility/Owner Name Facility IDk(if applicable) ft ft.
5416 Army Rd., Marshville 28103 ft ft i"
Physical Address,City,and Zip
21.REMARKS
Union 01-144-012R AUG d 0 6/.4
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: C!.-5.-.`.
(if well field,one lat/long is sufficient) /�/�. �(
N W ZGU 'L,. J ' 7/11/24
Signature oftertified Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 ElNo copy ofthis 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: 265 (ft.) 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of using: 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
Rta24a above, also submit a copy of this form within 30 days of completion of well
o
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) 8 Method of test Air 24e.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