GW1--02778_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: ; ,
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION '
Well Contractor Name 57 ft. 63 ft. I , 12 gpm
fir. i -f..r. ,°
2465-A �` Lam- . 76 ft 85 ft } 18 gpm
l.' 3..,.,'' , 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Hcable)
NC Well Contractor Certification Number `
- FROM TO,. DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAY W i 2024 0 ft. 55 ft. 6 1/8 in. SDR-21 PVC
Company Name ram.;• 16.INNER CASING OR TUBING(geothermal closed-loop)
P Y IT%+ti�V .i•4^,i� 7,fCa.^, •,rv'.-„a u FROM TO DIAMETER , THICKNESS MATERIAL
23-207 �~
2.Well Construction Permit#: �t�2';,ti;? r ft ft is
List all applicable well permits()a County,State,Variance,Injection,etc.)
ft. ft. i,a'
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. m
❑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 fL 20 fc 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 ❑Stbrnwater Drainage I
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 10 rt. Red Dirt
9/12/23 10 ft* 45 ft• : Soft Brown Dirt
4.Date Well(s)Completed: Well ID#
45 ft• 185 ft Blue Rock
5a.Well Location: ft. ft. '
Jason & Sarah Curtin ft. ft.
Facility/Owner Name Facility BM(if applicable) •
Seams:'S7—12g,76—18g,93, 105, 115'
ft. ft.
6641 Old Settlers Rd,Waxhaw 28173(Settlers Creek Lt 4) • ft ft.
Physical Address,City,and Zip 21.REMARKS -
Union 05-096-002D
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) / ', / ,
N �, "° iZ�L W. 10/1/23
Si a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
• with 15A NCAC 02C.0100 or 1SA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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: 185 (ft) 24a. For All Wells: Submit this fomi within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3 ,200'and 2@100) construction to the following:
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10.Static water level below top of casing: 30 (I ) 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: I I 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 30 Method of test: Air Also submit one copy of this fort 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
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