GW1-2022-04349_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: )�Y;_T— •
Dwight L. Huneycutt 14.WATER ZONES t
g Y FROM TO DESCRIPTION
Well Contractor Name APR 1 7W? 96 fL 100 fL 1 gpm
4070-A 107 fL 125 fL 1 gpm
NC Well Contractor Certification Number �tR..v.a!t' >1 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM T MATERIAL
Derry's Well Drilling, Inc. '' ~; 'sfv'l+i�^� ^' Ir I� O DIAMETER THICKNESS
0 ft• 84 ff• 61/8 i" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
10012447 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, is
List all applicable well permits(i.e.(.ounty,State,l'artance,Injection,etc.) ft. fit. i"•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft i"
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rrri ation 0 ft. 3 ft- Bent. Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fit. 35 fi- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if Imessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock IyM grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 21 ft. Red Dirt
4.Date Well(s)Completed: 9/9/21 Well iD# 21 ff• 58 ft. Brown Dirt
58 ff• 125 ft• Brown Granite
5a.Well Location: 125 ff• 145 ft' Blue Granite
Terry Hunter Wilson Y 145 fit 230 fL Brown Granite
Facility/Owner Name Facility ID#(if applicable)
230 ft- 305 ft. Blue Granite
7200 Davis Rd, Charlotte 28227
ft. R.
Physical Address,City,and Zip 21 REMARKS
Mecklenburg 137-043-05 Seams:96'=1g, 107'=1g, 125',135',145',230',290'
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 � ` 9/27/21
Signature Well Contractor Date
6.is(are)the well(s): ❑Permanent or ❑Temporary By.signing this form, I hereby certify that the well(y)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑No copy afthis 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 it'necessary.
P'or multiple injection or non-waler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
h'or multiple wells list all depths ifdierent(example-3 cr 00'and 2«100') construction to the following:
10.Static water level below top of casing: 59 (fL) Division of Water Resources,information Processing Unit,
Ifnvater level is abate casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 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 Nattual Resources—Division of Water Resources Revised August 2013