GW1--02736_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
L. Huneycutt 14.WATER ZONES . ,
Dwight
Y FROM TO DESCRIPTION.
Well Contractor Name 288 ft- 290 ft- ! 1 6 gpm
4070-A (.., '_.`..=: N ;�:�r. ft. ft.
��.��.,_...�!�...;_ `fir' �._.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
MAY Y 7 l�L`� FROM TO DIAMETER THICKNESS MATERIAL
f'i Derry's Well Drilling, Inc. o ft- 48 ft- 6 1/8 SDR-21 PVC
Company Name lr,:�,i?,.^�i;.,71 P::-,.,5.5,E_x:( l„I 16.INNER CASINGOR TUBING(geothermal closed-loop)
23-37�', ti 1' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V`��'� ='3 ft. ft. I is
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
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) OResidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.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 ❑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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 28 ft. Brown Dirt
2/22/24 28 ft- 35 ft i Junky Blue Rock
4.Date Well(s)Completed: Well ID#
35 ft• 400 ft. Blue Granite
5a.Well Location: ft. R.
Wanda& Malcolm Mayer ft. ft
Seams:51',56',62',66',89',94',99', 110'
Facility/Owner Name Facility ID#(if applicable)
ft n 122',150', 163', 171', 190',216',244',
4512 Raymond Austin Rd.,Waxhaw 28173(Devine Farm Minor Sub.,Lt1)
ft ft. 278',288-290'=6g
Physical Address,City,and Zip
21.REMARKS
Union 06-036-006E
County Parcel Identification No.(PIN)
sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W DG(teVttl—. ri/UP/Aralt- 3/14/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 'Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)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 l]No copy of this record has been provided to the well owner.
If this is a repair,fell 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: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
i
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 Infection Wells ONLY: In 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: f
(ie.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) 6 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. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resoiaces Revised August 2013
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