GW1--02687_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
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 I
Well Contractor Name 17, .---- :l ''s ;* i'-,, 638 ft• 640 ft• I I 2 gpm
2465-A ` ' -s' V S"" ' 646 ft• 650 ft. I I 18 gpm
NC Well Contractor Certification Number MAY co 7 2024 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER, THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 56 It 6 1/8 •in• SDR-21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name C�J t,C,j
10013786 OG
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(l 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
fL ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
❑Industrial/Conunercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft. 3 it Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑ coYery 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 OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. •
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks) 0 it 45 ft• Brown Dirt&Rock
4.Date Well(s)Completed: 5/9/23 We ID# 45 ft- 660 ft Slate
ft. ft.
5a.Well Location: ft. ft•
Kimberly Brown ft ,
Seams:70,75,238',308,335,355',435,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 465',535',605',638'=2g,646'=18g
11734 Brief Rd, Charlotte 28227 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 197-154-13
County - Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) J ,
N W g' w• 5/25/23
Si a4 of Certified Well Contractor Date
6.Is(are)the well(s): lr7Permanent or ❑Temporary By signing this form,I hereby certt&that'the well(s)was(rvere)constructed in accordance
wills 15A NCAC 02C.0100 or 15A NC.AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1No 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: 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: 660 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ft-different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (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
Rotary24a 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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