GW1-2022-04312_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:
Huneycutt 14.WATER ZONES
John W. l
FROM TO DESCRIPTION
Well Contractor Name 137 ft. 145 ft 3 gpm
2465-A - ; n.
ft.
IS.OUTER CASING for mutcased wellsONf o licableNC Well Contractor Certification Number DMETR SFROM O MAT ERIAL
Derry's Well Drilling, Inc. 0 fL 79 ft 6 1/8 in I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
19-239 FROM TO DLIMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. in,
List all applicable well permits(i.e.County,State,V-YIi idejlnociion,etc.)
ft. ft.
3.Well Use(check well use): V.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) fL fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 h- Bent.Chips Gravity
Non-Water Supply Well:
3 ir. 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fL
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,haMness,soi0rack in sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 16 ft. Brown Dirt
4.Date Well(s)Completed: 12/27/21 Well ID# 16 rt. 554 ft Brown Rock
54 it 300 ft- Blue Rock
5a.Well Location: ft. ft.
Tim Richardson fL fL
Facility/Owner Name Facility ID#(if applicable)
iL ft. Seams: 110', 125', 137'=3gpm,278',
218 Barra Dr., Waxhaw 28173 (Aubert Landing Lt17) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 05039106
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latAong is sufficient) / '�,�
N �, �l�i ti(/. 1/20/22
St lure of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,1 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 ElNo copy ofthis 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
S.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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 48 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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 IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 3 Method of test: Air 24c.For Water Supply&Injection Wells:
(gp ) 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013