GW1--05052_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATERZONES
Y FROM TO DESCRIPTION
Well Contractor Name . ,,,� 206 fc 215 fr. 1 6 gpm
2465-A R ECf 1�VF " n R.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.licable)
A U G 0 A 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 48 ft 61/8 in• SDR-21 PVC
Company Name In 3rui+ ti rl Pr.r r s y „9 tjra 16.INNER CASING OR TUBING(geothermal closed-loop)' '
22-339 D�=r`A r`3tY» FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
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) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 TO MATERIAL EMPLACEMENT METHOD
fG ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rocktype.grain sire,ere)
❑Geothennal(Heating/Cooling Return) DOther(explain under#2I Remarks) 0 ft• 10 rt. Red Clay
3/23/23 10 ft 30 fa Brown Sandy Dirt
4.Date Well(s)Completed: Well 1D#
30 f'• 245 fr. Granite
5a.Well Location: ft. ft.
Sergio Gonzalez R. ft
Facility/Owner Name Facility 1Dt#(if applicable)
it. ft. Seams:55',88', 113', 177', 185',
6422 Rehobeth Rd., Waxhaw 28173
ft 206'=10gpm
Physical Address,City,and Zip 21.REMARKS
Union 05-147-001H
County Parcel identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/longis sufficient) /'
N W C,i "" 'J
rett- 4/20/23
Signat#of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or ElNo 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 e21 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 with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All WSubmit ells: this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 36 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'• " 1617 Mail Service Center,Raleigh,NC 27699-1617
I t.Borehole diameter: 6 (in.) 24b.For Injection 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: 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
10 , Air 24a For Water Supply&Injection Wells:
(gpm)
13a.YieldMethod of test: 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 ;
I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013