GW1-2022-10040_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY: j
Ibis form can be used for single'or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
DWI t i
9 Y FROM TO DESCRIPTION
Well Contractor Name �.�'�P. G°"' 138 ft. 145 ft' I I 35 gpm
4070-A Z *G'r 1°'®'S fG fG
NC Well Contractor Certification Number n i O`1 ry q O�� 15.OUTER CASING for multi cased wells OR LINER if applicable)
NOV t L FROM TO DIAMETER THICIQHESSI MATERIAL
Derry's Well Drilling, Inc. Un 2 96 ft. 61/8 SDR-21 I PVC
Company Name in crFrra;t�� a 16.INNER CASING OR TUBING eothern al dosed-loop)
22-52 FROM TO DIAMETER THICKNESS MATERIAL
2.well Construction Permit#: fr. ft. , ,
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fG fL lin.� �
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fG fG in. i
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fG ft. in
❑Industria/Commercial ❑Residential Water Supply(shared) 18.GROUT
, FROM I TO MATERLII.' EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fG 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a Bcable '
FROM TO MATERIAL' - I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soi0roek type,grain she eec
❑Geothermal(Heating/Cooling Return). d0ther(explain under#21 Remarks) 0 ft- 30 fG Wet Red Clay
4.Date Well(s)Completed: 9/2/22 Well ID# 30 fG 73 ft + Wet BiOWrI Clay.
73 ft- 115 f" Brown Granite
sa.well Location: 115 n 165 f" Blue Granite
April Daniels fG fL
Facility/Owner Name Facility ID#(if applicable)
6322 Providence Rd S, Waxhaw 28173 fG fG Seams: 115�,130�, 138-145�=35gpm
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 05-063-007 j
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutestseconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sutficieot)
N W r f I,C�LP�f ' 9/30/22
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that%he ivell(s)was(1vere)constructed in accordance
with ISA 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 ONO copy of this record has been provided to the;well owner.
If this is a repair,fill out knmvn 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: construction details. You may also attach additional pages jf necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (fti) 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:
10.Static water level below top of casing: 17 (fi) Division of Water Resources,Information Processing Unit,
If evater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfectioutype: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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