GW1-2022-04282_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES t
FROM TO DESCRIPTION
Well Contractor Name 85 ft. 90 ft. 2 gpm
2465-A
385 ft 395 ft- 2 gpm
NC Well Contractor Certification Number APR 20�7 IS.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 57 ft 61/8 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
r - FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 19-237,Y;�l; ,;-,;.„,i i' ,"�i. R. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. It.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft % in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 1 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 it Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
ft. ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness sail/_ck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft. Brown Dirt
4.Date Well(s)Completed: 12/28/21 Well ID# 11 ft- 41 ft. Brown Rock
41 fl• 425 " Blue Rock
5a.Well Location: ft. R.
Tim Richardson ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams: 70',85'=2g, 117', 130', 152',
212 Barra Dr., Waxhaw 28173 (Aubert Landing Lt18)
rt. ft. 385'=2g
Physical Address,City,and Zip 21.REMARKS
Union 05039107
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iattlong is sufficient)
N W 1/20/22
Signa of Certified Well Contractor Date
6.Is(are)the well(s): [OPerrrlanent or ❑Temporary By signing this farm,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 0No 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 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 INSTUCTIONS
9.Total well depth below land surface: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 46 eft) 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 Iniextion Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, 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) 4 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: 112 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