GW1-2023-01605_Well Construction - GW1_20230214

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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: 11
Derry L. Huneycutt 14.WATER ZONES k. I
FROM TO I DESCRIPTION I
Well Contractor Name r 95 ft' 100 ft I I 79pm
2663-A " r ,ts' 120 1t 135 fLI I 39PM
NC Well Contractor Certification Number �" 15.OUTER CASING for multi cased wells!OR LINER if o finable
FEBE a ���� FROM TO DIAMETER d I THICIINESS. MATERIAL
Derry's Well Drilling, Inc. 1 0 ft 191 ft 161/8 k; ji SDR-21 PVC
Company Name 22-193 niti,iieFi{ '�' r '� :F�l�ri:`! FROM�RCTSOINGORTUB DIAMETER
closed-loop)
MATERIAL
2.Well Construction Permit#: "`` ��h7 ft ft in
Lis[of/applicable we!!permi(s(i.a County,Slate,Variance,Injection,etc.) ft I ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
❑Irri atidn 0 ft' 3 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 a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To nIATERIAL EMPLACEMENT METHOD
ft. ft
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❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer 5.305
TO DESCRIPTION color,hardness,soi0rock a in she,ea.
❑Geothermal(IIeating/Cooling Return) ❑Other(explain under#21 Remarks) 10 Red Dirt
10/27/22 20 ft I' Brown Dirt
4.Date Well(s)Completed: Well ID# 85 ft Junky Rock
sa.Well Location: ft Blue Rock
Jeremiah Scully ft ._Facility/Owner Name Facility ID#(ifapplicable) Seams:95=7gpm, 115', 120-135-3gpm,
ft I, 230'
6307 McNeely Rd.,Waxhaw 28173(Chandler Woods,Lt 4) n
Physical Address,City,and Zip
21.RE11fARKS I
Union 06-084-147
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one 1at11ong is sufficient)
N W D� 11/15/22
Signature of C fied Well Contractor Date
6.IS(are)the wens) pPefTnanent or ❑TeIDporaly By signing this form,I hereby certify that the wells)ivas(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 allo copy of this record has been provided to the,veil oivner.
If(his is a repair,fill out known well construction information and explain the nature of the
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 to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-watersupply Swells ONLYwith the saute construction,you can I,
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
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing:
36 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699461;
11.Borehole diameter: 6 (in.) 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: ry 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) 10 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: 112 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