GW1-2023-01619_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt c }� '�"` 14.WATER ZONES
'1.�y„,r FROM TO I DESCRWTIONI
Well Contractor Name 202� 60 ft 66 ft' I I 25 gpm
4070 A ft ft
NC Well Contractor Certification Number iniCFr<. � '4^' yu`tiir i�fi,t 15 OUTER CASINGformuDlAMLiERI1W1 OTIIICKNESsa hMATERIAL
i y'dfn
Derry's Well Drilling, Inc. ' o ft 51 ft 6 1/s !i°•' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(eothernud dosed-loonl
19-216 FROM TO DIAMETER', TIUCKNESS MATERUL
2.Well Construction Permit#: ft. ft .-I
List all applicable well permits(1.e.County,State,Variance,Injection,etc.) ft ft din.!
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft in
❑Industrial/Cormmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri anon •
Non-Water Supply Well: 0 R' 3 n- Bent.Chips Gravity
❑Monitoring ❑Recovery 3 & 20 ft Bentonite Pumped
Injection well:
ft ft I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stotmwater Drainage I i
ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock type,prain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 ft Red Dirt
9/3/22 10 30 ft Brown Dirt
4.Date Wei(s)Completed: Well ID#
30 ft 145 st I, Blue Rock
5a.Well Location: ft ft
Tim Richardson ft ft
Facility/Owper Name Facility ID#(if applicable)
242 Barra Dr.,Waxhaw 28174(Hubert Landing, Lot 13) ft ft Seams:60-66'=25gpm,90', 130'. 137'rt ft
Physical Address,City,and Zip 21.REMARKS
Union 05039022
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/Ininutes/seconds or decimal degrees:
22.Certification:
(ifwefi field,one Wong is sufficient)
N w 7�/_ u�.u�cd�'
9/30/22
Signature of ertified Well Contractor j Date
6.Is(are)the well(S): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?]No 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 421 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
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 form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 21 (ft) Division of Water Resources,,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary. 24a above, also submit a copy of this`•form within 30 days of completion of well
12.Well construction method: 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.Yield 24c.For Water Saaply&Infection Wells:
(gpm) 25 Method of test: Air 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 idei artment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resoutces Revised August 2013
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