GW1-2021-05868_Well Construction - GW1_20210709

E
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fort can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 240 rat• 245 R• '.' 1 gpm
4070-A 1 335 R 340 R I 2 gpm
NC Well Contractor Certification Number �1 1L p 9 202` 15.OUTER CASING for malti�ased wells OR LINER if a licable
v FROM TO DIAMETER T�CKNESS MATERIAL
Derry's Well Drilling, Inc. n SS-In(g Uni o R• 6o R 6 1/8 ;in SDR-21 PVC
Company Name 1nf3`I'('3
r, er 16.INNER CASING OR TUBING eothermal closed-loop)
20-490 D\"NR 5n`jlpll FROM TO DIAMETER Tl1ICKNESS MATERIAL
2.Well Construction Permit#: R. R. iv.
List all applicable well permits(i.e.Coumt,State,Variance,Injection,etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SITE THICKNESS NIATF.Rret.
R. R. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R' 1D
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERM L EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 R. 3 R Bent.Chips Gravity
Non-Water Supply Well:
3 R' 35 R' Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R R.
❑Aquifer Test ❑Stormwater Drainage
R. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG Wineh additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,herds soll/rock type,gram' size etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 R• 16 R Brown Dirt
4.Date Well(s)Completed: 4/9/21 Well ID# 16 R• 22 R. Brown Rock
22 R 445 R Slate
5a.Well Location: It. It.
Matt Nichol R. rat•
Facility/Owner Name Facility ID#(if applicable)
5313 McWhorter Rd, Waxhaw 28173 R• rat' Seams:77', 125,240'=1g,330',335=29
R. R.
Physical Address,City,and Zip 21 REMARKS
Union 05014009E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) /
N W �rv�ct-,L.. �, 5/4/21
Signature of CerWfied Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance
with I SA 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 sane construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list an depths ififi erent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing:
47 Division of Water Resources,Information Processing Unit,
(ft.)
If,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 24b.For Iniection 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,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 3 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 i Revised August 2013
f
{ I
i i