GW1--07696_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells • I
1.Well Contractor Information: 1
Dwight L. Huneycutt WATER ZONES •
DESCRIPTION I
Well Contractor Name 111 ft. 120 ft. I ' 4 gpm
4070-A - ft. ft. I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 83 +t- 61/8 is SDR-21 PVC .
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-170 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft M.
List all applicable well permits(.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) EJResidential 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: 3 ft 20 ft. Bentonite Pumped❑Monitoring ❑Recovery ft ft. ,
_
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) l
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT DH TROD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft.
l7Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain see,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 21 It. ' Brown Dirt
8/4/23 21 n• 53 ft Brown Sandy Dirt
4.Date Wells)Completed: Well 100
53 ft. 75 ft. Brown Granite
5a.Well Location: 75 it 325 ft Blue Granite
Stephen Lingo ft. ft.
Facility/Owner Name Facility ID#(if applicable) •
9624 Huey Blvd,Waxhaw 28173(Huey Estates,Ph2, Lt25) ft ft Seams:111'=4gpm, 177-181'
ft fr. i
Physical Address,City,and Zip 21.REMARKS a. —" , -?'r --,•
Union 05-051-042 -- ,--r e- ,, lj = :i )
County Parcel Identification No.(PIN) NOV 2 9, 2O2
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: �
(if well field,one lat/longissufficient) ID+ter ,c`:;i^); �•
N W 8/3`1/23 L. ;Pf
LA L.i
Signature of Certified Well Contractor 1 Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 154 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes 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
i
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
S.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: 325 (ft.) 24a. For All Wells: Submit this forte within 30 days of completion of well
For multiple wells list all depths if different(example-3 a�00'and 2@100) - construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 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
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 department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013