GW1-2023-02642_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt FR.WATER zolvEs
ROM TO I DFscaIl7lox
Well Contractor Name r 196 ft' 202 ft 8 gpm
2465-A ;_ - ,. ft. R.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cast d wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR 1 2023 0 f6 118 ft. 61/8 in.
SDR-21 PVC
Company Name 'rl T :s' l 16.INNER CASING OR TUBING cothermaI closed-loop)
r,i -. ^; iJ.'",,t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22-207`�'.,µ; ft. ft. in
List all applicable irell permits(i.e.County,State,Variance,h jection,etc.)
ft. fr.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL f4 in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 3 1 Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. I &
❑Aquifer Test ❑Stormwater Drainage
ft. I ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUmek typq grain size,ctn
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 30 ft. Red Dirt
4.Date Well(s)Completed: 3/8/23 Well ID# 30 & 115 ft• Brown Dirt&Rock
115 ft. 325 & Granite
59.Well Location: & %
EHC Homes, LP ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft Seams:132',140', 196'—
—
8314 Tirzah Church Rd,Waxhaw 28173-The Farms at Heartwood,Lt7 8gpm,260',
tr. ft. 270'
Physical Address,City,and Zip 21 REMARKS
Union 05-162-011
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/niinotes/seconds or decimal degrees: 22.Certification-
(ifwell field,one lat/long is sufficient) �� J/
N �,y �� L(/. � 3/28/23
Signa of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the)vell(s))vas(ivere)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 ❑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#21 remarks section or on the back ofthis forth. 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 ONLYwith the same constriction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing' 38 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 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 health department of the county where
constructed.
I j
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013