GW1-2021-04465_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: C
This form can be used for single or multiple wells f
1.Well Contractor Information: I
John W. Huneycutt 14.WATER ZONES
J FROM TO DESCRIPTION
Well Contractor Name 100 n• 110 rt 15 gpm
2465-A 1 n. n.
NC Well Contractor Certification Number AllS.OUTER CASING for multi-cased wells OR LINER if a licable
v OM TO DIAMETER THICKNESS 11fA1ERIAi,
Derry's Well Drilling, Inc. PeSg�n9 0 n. 91 n• 6 v$ in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
1001 14Q91r{o��30��s$ FROM TO DWIETER, THICKNESS MATERIAL
2.Well Construction Permit#: n. n. In.
List all applicable well permits(i.e.County,State,Variance,Injection,arc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipalftblic n• n• in.
❑Geothemtal(Heating/Cooling Supply) ®Residential Water Supply(single) rt• rt• in.
❑lndustrial/Cotm ercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERW, EMPLACEMENT METHOD&AMOUNT
❑hrr ation 0 n. 3 rt• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 rt 35 n Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n n
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets U necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnins etc
❑Geothermal eating/Cooling Return ❑Other(explain under 021 Remarks 0 n• 16 n• Red Dirt
$/6/20 16 rt• 32 rt• Brown Dirt
4.Date Well(s)Completed: Well ID#
32 rt• 55 rt• Brown Rock
So.Well Location: 55 n 80 n Unconsolidated Rock
Christopher M. Croxton so n 165 rt Blue Rock
Facility/Owner Name Facility ID#(if applicable)
9619 Alexis Dr., Charlotte 26227 n• rt' Seams: 100'=15g,145'
n. n.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 197-0$5-13
Comity Parcal Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N ,,i, �l.CK.� 8/31/20
Si re of Certified Well Contractor Date
6.Is(are)the well(s): ©Permonent or ❑Temporary By signing this form,I hereby certify that the well(s)nns(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the mell owner.
#'this is a repair,fill out known well construction information and explain the nature of the
repair tinder#11 remarks section or on the back ofthis jam. 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: 165 (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 1@100) construction to the following:
10.Static water level below top of casing: 26 (ft,) Division of Water Resources,Information Processing Unit,
f nater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter- 6 (in.) 24b.For Infection 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) 15 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.
Font GW-1 North Carolina Department of Enviromnent and Natural Resources-Division of Water Resources Revised August 2013