GW1-2022-04289_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 1a.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ? _ 312 ft 320 ft 6 12 gpm
2465-A AP R � ft. ft
3 202?
NC Well Contractor Certification Number 15.OUTER CASING for muff cased wells OR LINER if o lieable
FROM TO DIAMETER THICIOWSS MATERIAL
Derry's Well Drilling, Inc. �;;;.;. ' ' ',,.,,, 0 ft- 158 ft- 161/8 In SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eatfl&I al closed400
,. FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#: 21-57" ft. ft. (nL
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
R. ft. in.
3.Well Use(check well use): 17.SEEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
ft. ft is
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ilri ation 0 rL 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 ft 35 ft Bentonite' Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERML EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier (t ft
❑Aquifer Test ❑Stormwater Drainage
tt fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock tyM grain dze,eta
❑Geothermal(Tieating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 13 ft Brown Dirt
10/15/21 13 fL 25 ft Brown Rock
4.Date Well(s)Completed: Well TD# 25 ft- 345 ft. Slate
5a.Well Location: ft. ft.
RG Real Estate rt ft
Facility/OwnerName facility lD#(ifapplicable) ft ft
7505 Lancaster Hwy,Waxhaw 28173(Wildwood Reserve Lt27) Seams: 70',96', 137',258',312'=12g
rt. rt
Physical Address,City,and Zip 21 REMARKS
Union 05-020-001 E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification•
(ifwell field one lat/long is sufficient)
N N, 10/25/21
Signa ofCertitied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary Ry signing this faros•I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A N:AC 02C.0100 or 15A NI:AC 02C.0200 Well Consiruetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner
jthis is a repair,fill out known well construction information and explain the nature of the
repair under ii21 remarks section or on the back ofthis 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 commuetion,you can
submit one firm. SUBMITTAL INS7'IICTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple wells fist all depths ifdijjerew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: Iniaddition to sending the form to the address in
Rota 24a above, also submit a copy of this form 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.]'field(gpm) 12 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. I
Farm GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013