GW1-2022-04288_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Huneycutt 14.WATER ZONES
John W. Hune
Y FROM TO DESCRIPTION
Well Contractor Name 156 f- 162 fL 7 gpm
2465-A a ' ft. fit.
NC Well Contractor Certification Number n p p �r1, 15.OUTER CASING for multi-cased wells OR LINER if a licable
1` FROM TO DIAMETER THICKNESS 51ATEPJAL
Derry's Well Drilling, Inc. 0 ft. 50 ft 6118 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
21—59 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a!`"^'"• i iL i' ""' ft. ft. in
List all applicable well permits(i.e.County,Slale,Variance,Injection,etc.)
fit. fL is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft fL
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrl ation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK If a 'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neecasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVroek tyM grivin ooze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 11 ft Brown Dirt
4.Date Well(s)Completed: 10/14/21 Well ID# 11 fL 21 ft• Brown Rock
21 ft. 180 fL Slate
5a.Well Location: ft. ft.
RG Real Estate ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft. Seams:79, 115', 156'=7g
7501 Lancaster Hwy,Waxhaw 28173(Wildwood Reserve Lt28) ft. fL
Physical Address,City,and Zip 21.REMARKS
Union 05-020-001 F
Comity 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 10/25/21
Sigro6re of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By,signing this form.I hereby certify that the well(s)was(sere)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC Olt'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 e21 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.
Par multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL iNSTUCfiONS
9.Total well depth below land surface: 180 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdoerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 38 00 Division of Water Resources,information Processing Unit,
Ifuater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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
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 OW-1 North Carolina Department of Environment and Natural Resources—Division of A'ater Resources Revised August 2013
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