GW1--07693_Well Construction - GW1_20231122

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:WATER ZONES- ---- -1. '-' - -
Y FROM TO DESCRIPTION
Well Contractor Name 55 ft 58 ft I i 2 gpm
2465-A 450 ft 460 ft I . 48 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 55 ft 61/8 I:ilt SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) •'- - -
22-454 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 OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 2Residential Water Supply(single) ft ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Mitigation 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 r 19.SAND/GRAVEL PACK(if applicable) - _ - •-. - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test CDStormwater Drainage ft. ft.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer - FROM TO DESCRIPTION(color,hardness,solVroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 ft I , Red Dirt
4.Date Well(s)Completed: 9/15/23 Well ID# 10 ft 15 ft I Brown Dirt
15 ft• 465 ft Blue Rock
5a.Well Location: ft ft. '
Wanda Nash Medlin
11 ft. Seams:55'=2g,85', 132', 137',212',220',
Facility/Owner Name Facility ID#(if applicable) ft ft 250:,255,290,347,370,450=48g
6508 Old Ridge Rd, Waxhaw 28173 ft • ft
Physical Address,City,and Zip
Union 05-093-004C - --... .r.•q....,i; atis4_m, + ?
County Parcel Identification No.(PIN) N 1 I 2 n t U r 2023
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient) in ,gelfrP /' J -V P._
N W
9130/23'_"::3J..
SigniXre of Certified Well Contractor Date
6.Is(are)the well(s): I27Permanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA 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 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: 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: 465 (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:
1
10.Static water level below top of easing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Rotary
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1 i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&InjectionlWells:
13a.Yield(gpm) 50 Method of test: Air ,
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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013