GW1--05129_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 163 ft 170 ft. 39Pm
2465-A fL fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 45 ft- 6 1/8 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
24-139 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit It: ft. ft. in.
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 fL in.
❑Agricultural OMunicipal/Public
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft in.
❑)ndustrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 rt. 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 OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage fL 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,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Brown Dirt
7/20/24 5 ft. 10 ft' Junky Rock
4.Date Well(*)Completed: Well IN/
10 ft. 400 ft Slate
5a.Well Location: ft fL
Brian Benton ft, fL
Seams:70',85', 103', 115', 130', 150',
Facility/Owner Name Facility ID#(if applicable)
5424 Army Rd.,Marshville 28103(New Salem Estates,Lot 18) ». ft 156', 183'=3g, 172', 176',275',310',317',
fL ft 375' '
'
Physical Address,City,and Zip 21.REMARKS %% . `'•'%.. `:' 7.-.
Union 01144012U 'I ,�((��
County Parcel Identification No.(PIN) A V G J 0624
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i s,`-•-• - )-- t'.
(if well field,one lat/long is sufficient) Di.',.....!'_-._;
N W l�GCZ- 8/15/24
Si a of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or OTemporary signing thisform,I herebytern that the well(s)was
BY 1;'�8 tIY (were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yea 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#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: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths idijferent(example-3@200'and 2@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