GW1-2022-10045_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:"
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES . S
n� ,. FROM TO DES
CRIPTION I
Well Contractor Name �� ,�.t•' ; VV It:L, 155 ft- 165 ft• r I 50 gpm
7 fL ft
NCOWeIIOContractor Certification Number NOV V 0 • 20 22 15.OUTER CASING for multi-cased wells DR LINER if a licablo
FROM TO. DIAMETER.' THICKNESS MATERIAL
Derry's Well Drilling, Inc. Ino;�r�;;�11'f.; �` g Unil 0 ft 1122 ft 61/8 'in"' I SDR-21 I PVC
Company Name YS UU 16.INNER CASING OR TUBING(geothermal closed-loo
22-140 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit ti: ft. ft. '�•.
List all applicable well pennits(i.e.County,State,Variance,Injection,eta)
ft. ft. lin..
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in. -
❑Geotheal(Heating/Cooling Supply) EiResidential Water Supply(single) fit ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL', EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery nite Pumped
3 ft. 20 ft- Bento
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL' I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. J ft.
❑Experimental Technology ❑Subsidence Control
20.DRELLING LOG attach additional'sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION,color hardness soil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under 421 Remarks) 0 ft- 63 ft- ;;Brown Dirt/Shale Rock
6/15/22 63 fL 71 fir• Wet Brown Dirt
4.Date Well(s)Completed: Well EM
71 ft. 113 fit. Junky Quartz/Brown Rock
5a.Well Location:
113 fir 185 ft. Slate
Tony Adcock ft ft.
Facility/Owner Name Facility IDM(if applicable)
1 ft. ft. Seams: 125',133', 155'=509
701 Turtlewood Dr., Waxhaw 28173
rt. rt.
Physical Address,City,and Zip 21.REMARKS .
Union 06054154
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 w
D� ,L, � t 6/30/22
Signature WCeftified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify 1hat'ilre well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lrJNo copy ofthis record has been provided to the well owner:
If Niis is a repair;fill out known well construction information and explain the nature of the i
repair under 421 remarks section or on the back offs is form 23.Site diagram or additional well details:
You may use the back of this page tti 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 fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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@100D construction to the following:
10.Static water level below top of casing: 15 (fit•) Division of Water Resources,Information Processing Unit,
Ifivater level is above casinguse'•+^ 1617 Mail Service Ceiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 1
(i.e.auger,rotary,cable,direct push,etc.) I
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 heal th'department of the county where
constructed, i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Reso Ices Revised August 2013