GW1-2022-04290_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:
Dwight L. Huneycutt 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name " )? 255 ft' 260 ft 2 gpm
e {
4070-A APR �� 390 fL 395 fL 2 gpm
2 ( IS.OUTER CASING for multi cased wells OR LINER if a licable
NC Well Contractor Certification Number FROM TO DIAMETER THICIQiESS MATERIAL
Derry's Well Drilling, Inc. o ft• 46 ft 6 1/8 in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-too
21-56 "y FROM TO DIAMETER THICKNESS MATERIAL
2.'*'Veil Construction Permit#: ft. ft. In
List all applicable well permits(.e.Coumy,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE 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) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ltri ation 0 ft' 3 tL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft Bentonite' Pumped
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if st cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ftMATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnma,soil/rock type,gmin arms,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 18 ft- Brown Dirt
10/29/21 18 ft. 26 ft. Brown Rock
4.Date Well(s)Completed: Well ID# 26 f- 400 ft- Slate
Sa.Well Location: for. ft
RG Real Estate fr. ft.
Facility/Owner Name Facility tD4(ifapplicable)
rL iL Seams: 88',92',95', 150-156',255'=2g,
7509 Lancaster Hwy,Waxhaw 28173(Wildwood Reserve Lt26) -ft. rL
390'=2g
Physical Address,City,and Zip 21 REMARKS
Union 05-020-001 D
County Parcel Identification No.(PM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one lat/long is sufficient)
N W � LULQ.c�.l,C�� 11/9/21
Signature of .ertified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(v)was 6vere)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or END copy of this record hav 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 ii21 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 attich additional pages if necessary.
Par 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: 400 _(ft.) 24a. For All Wells: Submit this fort within 30 days of completion of well
Nor multiple wells list all depths ifdoerent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing 39 (ft) 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 Iniection Wells ONLY: hi 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) 4 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 Rater Resortrce Revised August 2013