GW1--01913_Well Construction - GW1_20240325

• I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt la.WATER ZONES
f,,"^ ---,-n„ FROM TO DESCRIPTION
Well Contractor Name 5 6 `g:i ' 1i. iy Is 125 ft: 131 ft- I 5 gpm
4070-A 292 ft, 300 ft- I , 3 gpm
MAR
NC Well Contractor Certification Number 2 L, 2024 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER> 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. �- -n.P!-_'•(•rAvAi;:�,lIgN 0 ft• 96 ft- 61/8 lin SDR-21 PVC
Company Name DV,/kz-1)' 16.INNER CASING OR TUBING(geothermal closed-loop)
22-144 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft. ft. 'in.
List all applicable well permits(i.e.County,Stale,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 is
❑Geothermal(Heating/Cooling Supply) ?]Residential Water Supply(single) ft. it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery • 3 ft- 20 ft- Bentonite ' Pumped
Injection Well: •
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Text ❑Stoimwater Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 ft. 57 ft. Brown Dirt
a.Date Well(s)Completed: 11/15/23 Well ID# 57 ft- 71 ft- Brown Rock
71 ft- 89 ft. Junky Blue Granite
5a.Well Location: 89 ft- 325 ff Gray Granite
Robert West
D• Seams:125-131'=5g,210',268',275',
Facility/Owner Name Facility ID#(if applicable)
6315 McNeely Rd.,Waxhaw 28173(Chandler Woods Lt 2) Ft. is 283',292'=3g
ft, ft.
Physical Address,City,and Zip 21.REMARKS •
Union 06084145
County Parcel Identification No.(PIN) , '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient) Z7&u j,-�
N W � _ ; 11/30/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby witty that the wells)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 BNo 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 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: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3(g200'and 2@100) construction to the following:
t
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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
8 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013