GW1-2022-10068_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.wATERzoNEs. t
n^ FROM TO I DESCRUMONI
Well Contractor Name F `y1 152 ft 157 ft- 2 9Pm
4070-A 2o22
NC Well Contractor Certification Number N O r 15.OUTER CASING`for multi-casedwells OR LINER if a licable
' �." lJ r{e� FROM TO mAMETER� THICKNESS MATERIAL
Derry's Well Drilling, Inc. _��µ;,, ^. Ur j 0 ft 46 ft 61/8 SDR-21 I PVC
Company Name J�Pt '"5 16.INNER CASING OR TUBING(geothermal closed-loop)
21-62 FROM TO DUMETER, . THICKNESS MATERIAL
2.Well Construction Permit#: ft. e. I im.
List all applicable well permits fl.e.County,State,Variance,Injection,etc.J
ft, ft. in•'
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural' ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f ft in '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑hri ation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
❑Aquifer.Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
` ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer P35 "
TO DESCRIPTION color,6ardvess,soiurark a sire etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 26 ft Brown Dirt
4/6/22 35 & Brown Rock
4.Date Well(s)Completed: Well ID#
400 ft• Slate
5a.Well Location: R
RG Real Estate ft ft
Facility/OvinerName Facility lD#(ifapplicable) ft. ft Seams: 58',69', 116', 152-157'=2gpm
5117 Tom Starnes Rd, Waxhaw 28173 ft.
Physical Address,City,and Zip
21.REMARKS
Union 05-020-001 J
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22•Certification:(ifwell field,one Wong is sufficient)
N W e�A_Lf��it/_ 5/2/22
Signature of ertified Well Contractor Date
6.Is(are)the weq(s): ©Permanent or ❑Temporary
B1 signing this form !hereby certify that the;wells)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 ZINO 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 1,
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page 6 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-wafer supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 400 (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:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- 6 (in.) 24b.For Itiiection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: Rotary construction to the fo)lowing: II`
(i.e.auger,rotary,cable,direct push,etc.) I;
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
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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. i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013