GW1--05057_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:
Dwight L. Huneycutt 14.WATER ZONES..
g y FROM TO DESCRIPTION
Well Contractor Name F"';. ;M 1---.
4-'
- :; fa::rli 52 ft• 55 10 gpm
4070-A '• \'--k.»'C•; V 112 ft- 120 n• 90 gpm
NC Well Contractor Certification Number AUG(U A L q o a 3 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) '
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 48 ft 6 1/8 hi. SDR-21 PVC
Company Name Intorir `,Vl4r t i'r. 4 ►tog LJntt 16.INNER CASING OR TUBING(geothermal closed-loop) _
23-86 D`}' �'3'` 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. is
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
❑lrrigation 0 ft 3 ft Bent Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery •
3 ft 20 ft• Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL •
EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology 0 Subsidence Control •
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,ha,dness,soil/rock type.grain sac,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft. 17 ft Red Clay .
5/4/23 17 ft 31 ft Brown Dirt
4.Date Well(s)Completed: Well 1D#
31 ft• 125 ft Granite
5a.Well Location: ft. ft.
Mike Kopp _ ft. ft
Facility/Owner Name Facility ID/I(if applicable) - - ------
7114 Massey Rd., Waxhaw 28173 ft. a Seams:52-55'=10gpm,69',77',
112-120-90gpm
Physical Address.City,and Zip - -
21.RF.MARKR'
Union 05-066-010F
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlnng is sufficient) Z:7��
N `,1, 7 Vel-7 C a Z f t- 6/8/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certtfj'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.Is this a repair to an existing well: ❑Yes or 0No 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=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
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: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 - (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,we" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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
m 100 Method of test: Alr 24e.For Water Supply&Injection Wells:
13a.Yield(gpm) 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.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 .