GW1-2022-10054_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES,-.
Dwight L. Huneycutt FROM TO I DESCRIPTION
Well Contractor Name 210 ft' 217 ft I I 60gpm
4070-A �. ;C, $�O ft fr
15.'OUTER CASING for multi-cased wells OR LINER tf a livable
NC Well Contractor Certification Number NOV rr n O n n FROM TO DIAMETER,F I THICHIVFSS MATERIAL.
Derry's Well Drilling, Inc. ` L LL 0 ft-, 81 f� 61/8 SDR-21 PVC
Company Name Z G ra�U nh '16.'INNER CASING OR TUBING' edthermat closed-loop)'
P Y lnyviil'e:es:3D:1 i�f0�•..�"$...a
21-344 M 1Q/B0G FROM TO DIAMETER THICKNM MATERIAL Y
2.Well Construction Permit#: ft H• 1O
List all applicable well permits r1 a County,State,variance,Injection,etc.)
ft. ft is
3.Well Use(check well use): 7.SCREEN
Water Supply Well: FROM TO - _ DIAMETER SLOT SIZE THICKNESS MATERIAL,
ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) R]Residential Water Supply(single) f ft in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT'
FROM TO MATERIAL,'. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20, ft- Bentonite. Pumped
Injection Well: ft %
❑Aquifer Recharge ❑Groundwater Remediation 19.'SAND/GRAVEL PACK ifa licablc
FROM TO MATERIAL, EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,saftock size,etc._)_.
❑Geothermal eating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 17 ft ;; Red Clay
4,Date Well s)Completed: 9/1/22 Well EN 17 ft 69 ft Wet Brown Clay
( 69 ft 225 ft ,` Blue Granite
5a.Well Location: ft. ft
Derek&Tammy Jordan ft &
Facility/Owner Name Facility ID#(if applicable)
6404 Providence Rd S, Waxhaw 28173 ft ft Seams: 110', 115', 1 168',
,
fr. fr. I. 210-217'=60gpm,
Physical Address,City,and Zip 21.REMARKS' "
Union 05-063-007B
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 r�GuGt.L-. 9/30/22
Signature of Certified Well Contractor V Date
6.Is(tire)the well(s): [OPermanent or ❑Temporary
By signing this form,I hereby certify that the well(,)was(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 ElNo 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#21 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-watersupply wells ONLYtvith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (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 2@100) construction to the following:
17 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Center,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:
(Le.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 276994636
I3a.Yield(gpm) 60 Method of test: Air24c.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 Ib. 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
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