GW1-2021-04518_Well Construction - GW1_20210429

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt q !�; 14.WATER ZONES I
�i FROM TO DESCRIPTION I
Well Contractor Name 635 ff 642 tt' 50 gpm
2465-A p 2 9 2021 rt. rt.
NC Well Contractor Certification Number AC R I5.OUTER CASING for multFcaIAL
sed wells TOR LWER it a livable
TO
Derry's Well Drilling, Inc. „ „a i0t*1 ProCessin9 Ur1it o ROM rL rL 1611/8 R i" T SDRE21 MA RPVC
Company Name H. D 16.INNER CASING OR TUBING eother a[closed-loop)
20-581 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. rn•
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. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) KIResidential Water Supply(single)
ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lri ation 0 rL 3 fl Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft Bentonite' Pumped
Injection Well: ft. R.
❑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 launch additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soff/mck type,gnin sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 26 tt. Brown Dirt
rt rt
4.Date Well 1/14/21 26 645 Slates)Completed: Well ID#
5a.Well Location:
Roberto Bonilla
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7401 Walnut Crest Dr.,Waxhaw 28173 (Walnut Crest Lt7) Seams: 90', 117', 175', 197',216',
635'=50g
Physical Address,City,and Zip 21.REMARKS
Union 05014017
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C '6c •ation
(if well field,one lat/long is sufficient) ',, /
N W (�{/ 2/1/21
Sign ure of Certified WeII Contractor V Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this form,I hereby certify that the uvell(s)ivas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Hell 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'uell owner.
If this is a repair,fill out Amour well construction information and explain the nature of the
repair under 921 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 1NSTUCTIONS
9.Total well depth below land surface: 645 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
48 Division of Water Resources,Information Processing Unit,
(ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Cedter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this;forth within 30 days of completion of well
12.Well construction method Rotary 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) 50 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