GW1-2023-02613_Well Construction - GW1_20230410

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
cutt 14.WATER ZONES
John W. Hune
Y FROM TO I DESCRIPTION
Well Contractor Name ';. .` — 535 i4 540 ft' 12 gpm
2465-A '� d,y;a,;`,P, 550 it- 556 ft- 28 gpm
NC Well Contractor Certification Number n D p 15.OUTER CASING for multi-cased wells OR LINER if a licable'
At't1 1 ® 2023 FROM TO DIAMETER' THICIQVESS MATERIAL
Derry's Well Drilling, Inc. o f6 48 f4 61/8 iry SDR-21 PVC
' '�'�% :,.,.:1 i' � ,,_, t 16.INNERCASINGORTUBING(geothermal closed-loop)
Company Name .,...,J f/.S
11`+� ,J�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 100134051� ° ft. ft. in.
List all applicable well permits(I e.County,State,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIUIESS MATERIAL
ft. ft. in.
[]Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) fr ft. in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 fc Bent.Chips Gravity
Non-Water Supply Well:
bMonitoring ❑Recovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. &
❑Aquifer Test []Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain svc,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Brown Dirt
4.Date Well(s)Completed: 2/24/23 Well ID# 5 ft- 560 ft. Blue Rock
ft. ft.
So.Well Location: ft. ft.
Jennifer Pains ft fr Seams:65,75',80',90', 128', 138',234%
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
8816 Blaydon Dr., Charlotte 28227 ft. ft. 247',335',535'=12gpm,550'=28gpm
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 139-223-27
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)
N W 3/1/23
Sig0&e of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent 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 ENO copy ofthis record has been provided to the well owner.
If this is a repair,fell out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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 it jectio»or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 560 (fL) 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) 1 construction to the following:
10.Static water level below top of casing: 30 (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: (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:
(Le.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 276994636
13a.Yield(gpm) 40 Method of test: Air 24c.For Water Supply&IDiection 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 Eavironment and Natural Resources—Division of Water Resources Revised August 2013
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