GW1--02775_Well Construction - GW1_20240507

1 •
•
WELL CONSTRUCTION RECORD For Internal Use ONLY: I'
This form can be used for single or multiple wells t
1.Well Contractor Information:
Dwight L. Huneycutt 1144.WATER ZONES TO DESCRIPTION
Well Contractor Name 209 ft 215 ft I I 2 gpm
4070-A --. -�, r. :s - ft. i I
-,_...
NC Well Contractor Certification Number A Z. t,...,,L:i ail i.,..1 t5.OUTER CASING(for multi-rased wells)OR LINER(if ap.livable)
'FROM TO DIAMETER: THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAY cfr ; .7024 0 ft 69 ft 61/8 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-190 c `^ .7, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: hg.,-;�rrnA�;•,i i;;{,,,s,.�,t_,,,;, 1 'tf ft ft. in -
List
all applicable well permits(te.County,State,Variance,injection, b)L'J;i_'
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well , FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public m ,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑lrrigation 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
It. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 19 ft. Red Clay
4.Date Well(s)Completed: 1/22/24 Well Mil19 ft 58 ft- j, Damp Brown Dirt
58 ft 400 ft I, Blue Granite
5a.Well Location: ft. ft.
Tanner Design
n and Build
Facility/Owner Name Facility ID#(if applicable) ft ft. SeamS:77�,93', 175',209'=2g
ft. ft.
8508 Tirzah Church Rd.,Waxhaw 28173(Wildwood Meadows Lt 8) ft ft. . '
Physical Address,City,and Zip
21.REMARKS
Union 05-162-002J
County Parcel Identification No.(PIN) i,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W , GZI--. 2/15/24
Signature of rectified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 j -
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 ifdiferent(example-3®200'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
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:
(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) 2 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
I