GW1--05058_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: i
John W. Huneycutt 14.WATER ZONES'. .
Y FROM TO DESCRIPTION'
Well Contractor Name �1-.;:!'....' ' �"r,:: 105 ft- 115 ft- 2 gpm
2465-A ‘'L.. 1 i—4 ,, 151 ft- 160 ft• 3 gpm
NC Well Contractor Certification Number A U G 0 A 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER i THICKNESS MATERIAL •
Derry's Well Drilling, Inc. 0 ft. 45 ft. 6 1/8 in' SDR-21 PVC
iti>tcww-.tt..il ;-'! .-rl.vr. 1ilull -
Company Name � `� 16.INNER CASING OR TUBTNG(geothermal closed-loop)
23-153 Dl/`i./ZO( FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List al/applicable well permits(ie.Cimino:,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
ft. ft. ill.
❑Agricultural ❑Municipal/Public -
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. iL 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 ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) ,
FROM _TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery G Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) ' ..
❑Geothennal(Closed Loop) ❑Tracer • FROM TO DESCRIPTION(color,hardness.soidrock type,grain size,etc.)
flGeotherrnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 35 rt. Brown Dirt
6/2/23 35 ft.- 300 ft. Blue Rock
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: ft. ft.
Ryan &Shelbie Clancey ft. ft.
Facility/Owner Name Facility ID#(if applicable)
5721 Rehobeth Rd, Waxhaw 28173 (Jackson Hole, Lot 7) ft. ft. Seams:55',76',80',94', 105-115'=2gpm,
rt. ft. 151'=3gpm,210',256',285'
Physical Address,City,and Zip 21.REMARKS - _
Union 05-147-041G
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient) / //
N W .r9t0 0) tuf.¢ 6/16/23
Siguah of Certified Well Contractor Date
. 6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
• with ISA NCAC 02C.01t10 or 15A NCAC 02C'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Mies or ❑No 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#2I remarks section or on the hack 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 m ut-water supply wells ONLY-with the same construction,you can
submit one form. SUBMITTAL INSTUCTiONS •
9.Total well depth below laud surface: 300 •(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: 40 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: hi,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:
(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
5 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method 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.
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Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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