GW1--02776_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY; k
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This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
9 Y FROM TO DESCRIPTION I
Well Contractor Name i -w- .6� �• 5„-,;J..*4 253 ft• 260 ft• I i 2 gpm
,..` •4070-A ft. ft.
NC Well Contractor Certification Number MAY 7 2024 15.OUTER CASING(for multi-cased wells),OR LINER(if ap licable)
FROM TO DIAMETER I. I THICKNESS MATERIAL 'i
Derry's Well Drilling, Inc. If,•feis. .:,.., .'h. ,r.,,,,r F:r,,4r�, 0 ft- 80 ft• 61/8 ¶' ; SDR-21 PVC
., 16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name G y��;('4'+ LJ FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 23-189 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 OMunicipal/Public ft ft. is
OGeothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft ft. in.
❑Industrial/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:
OMonitoring ❑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 ❑Salinity 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,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft• 16 ft ;' Red Clay
4.Date Well(s)Completed: 1/19/24 Well ID# 16 ft• 54 ft Wet Brown Dirt
55 ft- 72 it I Brown Granite
5a.Well Location: i
Russell Tanner 72 ft- 400 ft Blue Granite
ft fr. Seams:91',97', 108', 115', 122', 128',
Facility/Owner Name Facility ID#(if applicable)
ft.8512 Tirzah Church Rd,Waxhaw 28173(Wildwood Meadows Lt 3) ft 133',226',231',249',253'=2g
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Union 05-162-002D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22 Certification:
N W ui.e1'"-- tt- 1/31/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): I27Permanent or ❑Temporary By signing this form,I hereby cert that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to the;tivell 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 1
submit one form. SUBMITTAL INSTUCTIONS ,,
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
1'
10.Static water level below top of casing: 30 (it) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: InI addition to sending the form to the address in
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 Mall Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
• 13a.Yield(gpm) 2 Method of test: Air 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. j
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water ResoureesIRevised August 2013
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