GW1--02773_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD • ForinternalUseONLY: I
This form can be used for single or multiple wells
1.Weil Contractor Information:
Dwight L. Huneycutt FROM WATERZONES DESCRIPTION
Well Contractor Name 115 ft• 120 ft. 5 gpm (154-165'=15 gpm)
4070-A f - 189 ft. 195 ft. j I 20 gpm
"+-` '~�\�• 'r 15.OUTER CASING(for multi-cased wells)OR LINER(if a iicable)
NC Well Contractor Certification Number a e.. t..f 8./ I-. 1,pp
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAY Cr 7 2074 o ft. 50 ft 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 24-Qr7`sp T: ^"•P‘-r,^..1`a:'4 7'g ii?id ft. ft. ;in•
List all applicable well permits(Le.Counry,State,Variande 1»j�c't'ie ii.Jid# ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public in
❑Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single) ft ft. 1O
❑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:
❑Monitoring ❑Recovery 3 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 Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soiVrack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 7 rt. Wet Brown Clay
4.Date Well(s)Completed: 4/22/24 Well 1D# 7 ft 19 ft• Brown Dirt
19 ft. 200 ft• I Slate
5a.Well Location: ft. ft. r
Zachary Cook ft ,_
Facility/Owner Name Facility ID#(if applicable) Seams: 115'=fig,154'=15g, 189—20g
ft ft. ,
6417 McWhorter Rd., Waxhaw 28173 ft ft
Physical Address,City,and Zip 21.REMARKS
Union 05-039-001 E
County Parcel Identifcation No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W Z7GUe -,c_.- 5/2/24
Signature of Ce fled Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certify 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 EUNo 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 I
9.Total well depth below land surface: (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: I;
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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
IL Borehole diameter: 6 (in.) 246.For Infection 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: s ,
(Le.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) 40 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