GW1--05036_Well Construction - GW1_20230804

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.WATER ZONEs
FROM TO DESCRIPTION
r 285 ft. 292 ft- 20 gpm
Well Contractor Name >,
2465-A �"'+'�'C= �L/ ft. ft.
A 1 iG 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number V U
IO 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 73 ft. 61/8 SDR-21 I PVC
ry 9 ,.,,,
Corn an Name r rW rCC , 16.INNER CASING'OR TUBING(geothermal closed-loop) ' .
p y Dtfi,5Q� L
22-65 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ' ft. ft. in.
List all applicable well permits(i e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: _ FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural' ❑Municipal/Public ft. ,n
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑IndustriallCommercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft- Bent.Chips- Gravity
Non-Water Supply Well: _
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft.
:Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) _
FROM - TO MATERIAL EMPLACEMENT METHOD
:Aquifer Storage and Recovery OSalinity 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 TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) , 0 ft- 60 ft- Brown Dirt
3/14/23 60 ft. 305 ft. Blue Rock
4.Date Well(s)Completed: Well LEW
ft. ft.
5a.Well Location: • ft. ft.
Kristopher Oxentine ft. ft:
Seams: 113', 122', 130-140, 160', 180,,
Facility/Owner Name Facility ID#(if applicable)
4735 Pimlico Ln,Waxhaw 28173(Queensgate Lots 6&7) ft 191',220',240',285'=20gpm
ft. ft
Physical Address,City,and Zip 21:REMARKS
Union 05-039-046
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N9&i.n/ 0). gi7ae-rezt—
3/31/23
Sid/attire of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary 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 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the ivell 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 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 INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level 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
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,direst push,etc.) • Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
2Q Air 24a For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013