GW1-2023-01618_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD
For Internal Use ONLY: �
This form can be used for single or multiple wells i
1.Well Contractor Information:
Derry L. Huneycutt 14.WATER ZONES f i
FROM TO I DESCRII'TTON
Well Contractor Name ( ,'; " ?-' ^, 188 f" 190 ft- 49pm
(�
ft ft
NC Well Contractor Certification Number FED I ;� 2023 15.OUTER CASING for multi-cased wens OR LINER if a livable)
FROM TO DIAMETER!, I THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 & 51 ft 6 1/8 'oi' SDR-21 PVC
CornPAY Name 16.INNER CASING OR TUBING eothermal dosed-lao
19-238 ti ,.-..,Gta'.t �v5'�ty FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. DIAMETER
id
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To I DIAMETER J,SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft in-
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) �' ft in
❑Industriat/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 fL 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 a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL:• EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,bardness,sawnck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 10 M Red Dirt
4.Date Well(s)Completed: 9/6/22 wen 1D# 10 ft 38 ft Brown Dirt&Rock
38 ft- 345 ft i, Blue Rock
Sa.Well Location: ft ft I•,
Tim Richardson ft. &
Facility/Owner Name Facility ID#(if applicable)
236 Barra Dr.,Waxhaw 28174(Aubert Landing, Lot 14) % " Searrls:90', 188'=4gpm,250',271'
ft ft
Physical Address,City,and Zip 21.REMARKS
Union 05039103
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) rL
N w 9/30/22
Signature of c�rtified Well Contractor V !' Date
6.1s(are)the well(s): 12]Permanent or ❑Temporary By signing this form,I hereby verity that the rveU(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 END 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
repair under 421 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 if necessary.
For multiple injection or non-water supply wells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtjjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resourc I es,1 Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 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: J
(Le.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) 4 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 de' artment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013