GW1--02774_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: ,
Huneycutt 14.WATER ZONES 1
John W. Hume
Y FROM TO DESCRIPTION
Well Contractor Name _ ,�� 230 f6 240 ft I 30 gpm
2465-A i .-- ....L ''i,`a/ r.,-L 1 ft ft
NC Well Contractor Certification Number MAY 1) 15.OUTER CASING(for multi-cased wells)OR LINER(if ap !kettle).2024 FROM TO DIAMETER! ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 48 ft 61/8 °a SDR-21 PVC
Company Name A pil't".v'rK:ItA;'F�:rtti;; ��at=,�i17,.tg: k 16.INNER CASING OR TUBING(geothermal closed-loop)
24-45 Id"ti(:y)'30-3 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 ft. in I,❑
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt ft. in
❑lndustrial/Commercial ❑Residential 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
Storage and Recovery OSalinity Barrier
ft. it. I.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/roek type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 35 ft. ' Brown Dirt
4/24/24 35 ft 265 ft. !, Granite
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Zachary Cook ft. ft,
Seams:68,97, 115, 135,, 145', 167,
Facility/Owner Name Facility ID#(if applicable)
6417 McWhorter Rd., Waxhaw 28173 f' ft. 175',230'=30gpm,246'
f6 ft.
Physical Address,City,and Zip 21.REMARKS
Union 05-039-001 E
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: •
(if well field,one lat/long is sufficient) // � �� //
N W Ip 4L w• 5/2/24
SiGr��rreee of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that ithe well(s)was(were)constructed in accordance
' with USA 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 ONo 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 rentarkt 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
I;
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'and 2(100) construction to the following: :1
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (R)
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection 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
(ie.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
P
24c.For Water Supply&Injectionells:W
13a.Yield(gpm) 30 Method of test: If 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 healthl department of the county where
I
constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013