GW1-2022-10078_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:
John W. Huneycutt 14.WATERZONES
Y FROM TO I DESCRIPTION I
Well Contractor Name 368 , fL 375 fL I 1 I 3 gpm
2465-A -�- ft. &
NC Well Contractor Certification Number V 15.OUTER CASING.for TA1,1 aced wells'OR LINER if o licable
FROM TO DLIMETER4 I THICKNESS MATERIAL
Derry's Well Drilling, Inc. �lnv iQ-7 9027 0 ft 49 It" 6 1/8 16J 1 SDR-21 I PVC
Company Name q 16.INNER CASING OR TUBING cothermaI closed-loop)
22-283 r. �'vil�ri c 1��3 U 11 FROM TO DIAMETER!- THICKNESS MATERIAL
2.Well Construction Permit#: £A ft. ft. ii'
List all applicable well permits(i.a County,State,Variance,InjectiFAW 0
ft. ft. is
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: FROM TO DIAMETER I -SLOT SIZE THICKNESS MATEmAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft fL is
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft. Bent.Chips,. Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 tt. Bentonite: Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ficable
140f-
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. I
❑Aquifer Test ❑Stormwater Drainage
fl.
❑Experimental Technology ❑Subsidence Control
NG LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION(color,hardness saitrock a rain she etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 35 fL Brown Dili
4.Date Well(s)Completed: 8/16/22 Well ID# 40 ft. Shale Rock
700 ft. ;; Blue Rock
5a.Well Location: . ft.
Tina Rinaldo ft.
Facility/Owner Name Facility ID#(if applicable)
9115 Providence Rd. S, Waxhaw(Simpson Acres W) rt t` seams.::110', 150',205',227',250',316',
rc ft. 368'=39pm,451',494',605'
Physical Address,City,and Zip 21.REMARKS
Union 05-051-006M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) �
N `,It 9/13/22
Sign of Certified Well Contractor Date
6.Is(are)the well(s): OPermaDent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
7.Is this a repair to an existing well: []Yes or DNo' 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 of this farm. 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 ofwells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 700 - (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@100� construction to the following:
10.Stade water level below top of casing: 52 (ft.) Division of Water Resources,Information Processing Unit,
Ifevaier level is above casing,use"+" 1617 Mail Service Center Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Injection Wells ONLY: Inladdition 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 27699-1636
13a.Yield(gpm) 3 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 Ib. well construction to the county health department of the county where
constructed. f I
Farm GW-I North Carolina Department of Environment and Natural Resources—Division of Water Res(I Revised August 2013
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