GW1-2022-10035_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells If+
1.Well Contractor Information:
John W. Hume cuff 14.WATERZONES i
Y a- a Z �' �', FROM TO DESCRIPTION I i
` tt. i
Well ConUactorName 132 ft 140 � $gpfp
2465-A NOV O ? 2022 ft %
NC Well Contractor Certification Number 15.OUTER CASING for Tg1__e1Is1 OR'LINER if a licable
FROM TO DIAMETER THTCIdVESS MATERIAL
Derry's Well Drilling, Inc. In orirra:�cn Prn-,pevin3 Unit 0 fr. 94 11, 6 1/8 in. ISDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
21-273 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit q: ft. ft. in. !
List all applicable well permils(i.e.County,Stale,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCENESS MATERIAL
❑Agricultural ❑Municipal/Public % n• in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft, in
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL i EMPLACEMENr METHOD&AMOUNT
❑Irri ation 0 ft. 3 it. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft, Bentonite 1 Pumped
Injection Wcll: fa 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 ❑Stonnwater Drainage
it. ft. I '
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional ifnecccsa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colur,hardness,soil/rock in size,etc
❑Geothermal eating/Cooling Return) ❑Other(explain under 421 J
0 ft- 10 ft. Red Dirt
4.Date Weil(s)Completed:
7/11/22 Well ID/f 10 ft- 85 ft. Brown Dirt&Rock
85 tt 200 it• Slate
Sa.Well Location: ft. ft
Alexander Gurlova tt ft
Facility/Owner Name Facility ID#(if applicable)
6996 Potter Rd., Matthews 28104 ft ft' Seams: 106',114', 117',132'=8gpm,139',
ft. it 194'
Physical Address,City,and Zip 21.REMARKS
Union 07150001 V
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) I r
N W 9a
,G/iy rn(,/ 7/21/22
Sign4&e of Certified Well Contractor 4P Date
6.Is(are)the wcll(s): ©Permanent or ❑Temporary
13y signing this form,I hereby certify ghat theiivell(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 ONo copy of this record has been provided to the ivell owner.
if this is a repair,fill out known ivell construction information and explain the nature of the
repair under 421 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 aM.1'with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
I.
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths ifdioerent(example-3@200'and 2@100) construction to the following:
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10.Static water ievel below top of casing: 32 (ft.) Division of Water Resources,information Processing Unit,
Ifrvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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II.Borehole diameter- 6 (in.) 24b.For iniection Wells ONLY:,!Iti 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: Rotary - 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) 8 Method of test: Air 24c.For Water Supply&Inicction 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. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wate RI ounces Revised August 2013