GW1--05056_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Dwight L. Huneycutt FR.WATER ZONES FROM TO
DESCRIPTION
Well Contractor Name 377 f• 380 ft. 3 gpm
4070A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS _ MATERIAL
Derry's Well Drilling, Inc. o ft 52 ff. 61/8 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
23-214 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: IL ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) li.GROUT
FROM -TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well: - —
❑Monitoring ❑Recovery 3 ft 20 ft' Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage
f4 ff.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain are,me.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 34 ft. Brown Dirt
4.Date Well(s)Completed: 7/1/24 34 ft. 42 ft- Brown Rock
Well EN
42 ft• 500 ft Slate
5a.Well Location: ft. ft.
Russell Tanner
ft. ft. Seams:56',63',75',89',94', 110', 127',
Facility/Owner Name Facility Il)N(if applicable)
5105 Tom Starnes Rd, Waxhaw 28173 ft 138', 156', 179', 195',211',217',267',
ft ft 279',315',377'=3g,441'
Physical Address,City,and Zip 21.REMARKS
Union 05-020-001R r--
. i=: ill' ,i.,
County Parcel Identification No.(PIN) L1 l
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification: A U G J 9 L6 24
(if well field,one lat/long is sufficient)
N w P'�L r .. TF45/24, '..;r
Signature of fled Well Contractor C i'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/SA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E)No 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 42I 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: 500 (m) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and?@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
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:
(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) 3 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013