GW1-2022-10059_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
John W. Hume cuff 14.WATER ZONES
. 4
Y FROM TO DESCRIPTION I
Well Contractor Name u._ n 390 396 rt. I 15 gpm
q�
2465-A it ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
0 7 2022 FROM TO DIAMETER TIHCI-- MATERIAL
Derry's Well Drilling, Inc. NOVr 0 ft 133 ft 6 1/8 SDR-21 I PVC
Company Name �+j,�l[aY��'="j r'd 16.INNER CASING ORTUBING geothermal closed-loop)
i ,` r \S!L^U 3 7 FROM TO DIAMETER THICIC NESS MATERIAL
2.Well Construction Permit#: 21-151 J°° ft. ft fin.
List all applicable well permas(Le.County,State,Variance,Injection,etc.)
ft, ft. in. ,
3.Well Use(check well use):
17.SCREEN ),
Water Supply Well: FROM To DIAMETER SLOT SIZE I TMCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in
I
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft & in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 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 ft To ft. MATERIAL I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
ft. ! ft.
❑Experimental Technology ❑Subsidence Control '
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnem,soillroek sim etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 35 R Brown Dirt
4.Date Well(s)Completed: 3/15/22 Well ID# 35 ft- 106 ft Brown Rock
106 ft 425 ft Blue Rock
So.Well Location: ft ft
James A. Fox ft ft
Facility/Owner Name Facility ID#(if applicable)
2333 Autumn Blaze Ct.,Waxhaw 28173(Brantley Oaks U79) M to Seams: 147', 158', 180',210',230',291',
ft ft. 300',328',367',377',390'=15g
Physical Address City,and Zip 21.REMARKS I.
Union 06057056 1
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cc •leation-
(ifwell field,one lat/long is sufficient)-
N W (�{/ 4/12/22
Signa of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy that III lieivell(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 ElNo copy ofthis record has been provided to the,'well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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
S.Numberof 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: 425 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2@100) construction to the following:
10.Static water level below tap of casing: 36 (ft,) 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 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: 1f
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 15 Method oftest: 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.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013