GW1-2021-00840_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune cuff 14.WATERZONES
9 1 FROM TO DESCRIPTTON
Well Contractor Name 347 ft 350 ft• j 1/2 gpm
4070-A ft• ft i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weUl OR LINER tf a liable
FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 77 It 6 1/8 !" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING fizetithernial closed-l000l
21-214 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) tt. ft. 'in•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To I DIAMETER ',SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fL ft. to
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fa
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Olffigation te Supply Well: 0 It. 3 IL Bent.Chips Gravity
Non-Water
❑Monitoring ❑Recovery 3 ft- 35 ft. Bentoniie Pumped
Injection Well: It. 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 soiUrnek in shm.etc.
❑Geothermal (Heating/Cooling Return) ❑Other lain under#21 Remarks 0 ft- 62 ft BroWRyQlrf F i
6/11/21 62 IL 700 ft- Granite
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Joshua Starnes ft. ft.
Facility/Owner Name Facility ID#(if applicable)
3712 Tom Greene Rd, Waxhaw 28173 ft' ft- Seams:90', 110' 125', 177%210%255',
ft. ft. 347'=1/2g,488',635',670'
Physical Address,City,and Zip 21.REMARKS
Union 04318006
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) DG� I� /
N w l�/rV 8/15/21
Signature of Certified Well Contractor V Date
6.1s(are)the well(s): oPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constnicted in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FlNo copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#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 supph,wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 700 (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@100D construction to the following:
10.Static water level below top of casing: 200 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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 27699-16M
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24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1/2 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Res�urces Revised August 2013
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