GW1-2021-00827_Well Construction - GW1_20211208

S
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DWi ht L. HUne CUtt 14.WATER ZONES
9 Y FROM TO DESCRIPTION
Well Contractor Name 312 ft- 315 ft. i 2 gpm
4070-A 320 ft. 328 IL 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
PROM TO DUMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o IL 145 ft 6 1/8 j in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
20-616 FROM TO DIAMETER "UCKNESS MATERUL
2.Well Construction Permit#: tt. ft. in.List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. I 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.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERUL' EMPLACEMENT METHOD&AMOUNT
n-Water a❑Iter Supply Well: 0 ft. 3 ft. Bent.Chips Gravity
Non-
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I MATERIAL I EMPLACEMENT MEI•HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
It. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soil/rock in si etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under 421 Remarks 0 ri- 85 fL Dry Brown Dirt
4.Date Well(s)Completed: 9/18/21 Well ID# 85 ft- 112 R- Wet Brown Dirt
112 1" 135 ft• Brown Granite
Sa.Well Location:
Bryan Scott Yalich 135 ft- 345 fi- Blue Granite
IY ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. fL Seams: 152',312"1'2g,1320'=5g-i r
Tirzah Church Rd, Waxhaw 28173 (Ratchford Lt4) ft. I
Physical Address,City,and Zip 21.REMARKS
Union 05-129-003D 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one[at/long is sufficient)
N w D � � "� 10/12/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 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 9)No copy ofthis 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: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 44 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection 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) 7 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 healthi department of the county where
constructed.
I
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013