GW1--07691_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
,This form can be used for single or multiple wells I
•
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES • - • 1 - -.
9 Y FROM TO DESCRIPTION
Well Contractor Name 138 ft- 142 ft- I ' 2 gpm
4070-A 290 1G 300 ft- I , 5 gpm
NC Well Contractor Certification Number -15 OUTER CASING(for multi-cased wells)OR LINER(if ap licable) • - - -
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o f- 98 ft- 61/8 ! Ili SDR-21 PVC
Company Name' 16.INNER CASING'OR TUBING(geothermal closed-loop) -- -
23-198 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
ft.
❑Agricultural ❑MunicipaUPublic it in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ftft. in.
❑Industrial/Commercial :Residential Water Supply(shared) Is.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) - - -- -- • --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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/roek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- ft Red Clay
8/3/23 18 ft- 71 ft. Sandy Brown Dirt
4.Date Well(s)Completed; Well ID# '
71 - ft- 84 ft- !, Wet Brown Dirt
5a.Well Location: 84 ft. 385' ft. Blue Granite
Lorraine Mulligan rt. ft. . , -
Facility/Owner Name Facility ID#(if applicable)
8213 Tirzah Church Rd., WaXhaw 28173 ft. ft. 'Seams:104', 132',138'=2g,
ft. ft. 290'=5g
Physical Address,City,and Zip 21.REMARKS - -` --- ':- _
UkAion OS-1Sq-13°8 < 1.-,
County Parcel Identification No(PIN) N i i V f 2 i l 23
•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) :! i2).
�,._
,,(/ inT:: r.
Z7u).' ' L r r GGN�c_zieZ` 8/31+/23;"r :s�t :;:fi
Signature of edified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RINo 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 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 cons ruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 385 , (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ire/Is list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
n
10.Static water level below top of casing: 30 (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.) 246.For Iniection 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: ry construction to the following: I
(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) 7 Method of test: Air
24e.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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013