GW1--05050_Well Construction - GW1_20240830

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
Well Contractor Name 113 ft. 117 a 6 gpm
2465-A 210 a 215 ft. 1 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wdls)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 75 ft 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
24-23 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. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. 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: 3 ft- 20 ft. Bentonite Pumped
❑Monitoring ❑Recovery
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.
DAquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 40 ft. Red Dirt
2/14/24 40 ft- 60 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
60 ft• 305 ft Brown Granite
5a.Well Location: ft, ft.
Providence Custom Builders LLC a ft• Seams: 79',88', 113-117'=6g, 132-140',
Facility/Owner Name Facility ID#(if applicable)
6519 Rehobeth Rd., Waxhaw 28173 (Spring Valley, Lt 1) ft. • ft. 159', 179',210'=1g,242',248'
ft. ft.
Physical Address,City,and Zip 21.REMARKS l'
Union 05-147-068A l
County Parcel Identification No.(PIN) �l() J t} 4?
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: l'' ""
(if well field,one lat/long is sufficient) `` �� // i..`.• ..
N W
/LK, . 2/29/24
Si y l e of Certified Well Contractor Date
6.Is(are)the well(s): GEIPermanent or DTemporary By signing this form,I hereby certini that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA 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 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 al/depths if different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing 30 (ft.) 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 Iniection Welk 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.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 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013