GW1-2021-00831_Well Construction - GW1_20211208

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 1a.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 102 ft. 110 ft. 5 gpm
2465-A 165 ft 170 fi j 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER TIHC7QNES5 MATERIAL
Derry's Well Drilling, Inc. 0 fc 92 fL 161/8 j SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
21-261 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Constriction Permit#: ft. TO
'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
f6 fL in.
ZAgricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL'.. EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 1'a livable
FROM TO MATERIAL i EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fL i
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/ ck '•n etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 65 ft. Brown Dirt
4.Date Well(s)Completed: 10/18/21 Well ID# 65 fL 80 fL Junky Rock
80 fL 185 ft- Granite
5a.Well Location: ft. fL
Charlotte A. Springer
Facility/Owner Name Facility tD#(if applicable)
6522 Hue Rd, Waxhaw 28173 fL f` Seams: 102'=5g, 12 �
y ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 05104054
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one tat/long is sufficient)
N W 11/1/21
Sigqq6e ofC.,ified Well Contractor tl Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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 921 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: 185 (m) 24a. For All Wells: Submit this formi within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing:
25 (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 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: 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013