GW1-2022-10029_Well Construction - GW1_20221107

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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
Dwight L. Hume . r i
Y FROM TO DESCRUPTIONI
Well Contractor Name a 45 ft 250 ft. 2 9Pm
4070-A NOV (� r7 q 370 f° 376- ft- 23 gpm
NC Well Contractor Certification Number 4 V i L o 22 15.OUTER CASING"for multi-cased wefts OR LINER if a licable)
FROM TO DIAMETER, THICKNESS MATERIAL
Derry's Well Drilling, Inc. In`;�r„ tip, �r�^sx s f.7 ur p fL 103 ft 6 1/8 1'a; SDR-21 PVC
Company Name 16.INNER CASING ORTUBING eothermaldosed-loci
21-294 FROM TO DIAMETER,' THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. 'in.'
List all applicable well permits(i.e.County,Slate,Parlance,Injection,etc.)
f4 fL fin.
3.Well Use(check well use): 17.SCREEN f
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft f in.
❑Agricultural ❑Municipal/Public L in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' i
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL 6 EMPLACEMENT METHOD&AMOUNT
❑bTi ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 20 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL" I EMPLACEMENT METHOD
ft fL
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO qDESCRIPTION color,hardness,soitrock type,grain ' etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft Brown Clay
9/3/22 25 fL 71 fL ' Wet Brown Clay
4.Date Well(s)Completed: We11ID#
71 fL 125 ft Brown Granite
5a.Well Location: 125 ft: 385 ft Blue Granite
Paul &Christine Wiedenfeld 1r.
Facility/Owner Name Facility ID#(if applicable)
7011 Old Ridge Rd., Waxhaw 28173 fL seams:125',245'=29pm,370'=23gpm
Physical Address,City,and Zip 21.REMARKS
Union 05-096-067
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshnii mutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N 9/30/22
Signature o Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing flits forni,I hereby certify that die well(s)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 EINo copy of this record has been provided io 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 tins 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: 385 (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@100) construction to the following: 11
10.Static water level below top of casing: 18 (fL) Division of Water Resources,Information Processing Unit,
Ifwater 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:
(ie.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 276994636
13a.Yield(gpm) 25 Method of test: Air
24c For Water Supply&Infection W 11ILs.
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. I '
Form GW-1 North Carolina Department ofEnvnonment and Natural Resources-Division of Water Resources Revised August 2013