GW1-2023-02644_Well Construction - GW1_20230411

WELL CONSTRiJCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
cult 14.WATER ZONES
John W. HUne
Y FROM TO DESCRIPTION
Well Contractor Name 242 ft- 250 ft. 10gpm
2465-A 1� 276 & 280 2 gpm
15.OUTER CASING for multi-cased wells OR LINER If a Hcalile
NC Well Contractor Certification Number /�;Y, .� FROM TO DIAMETER TfIICKNESS MATERIAL.
Derry's Well Drilling, Inc. t 2023 0 ft. 65 ft 6 1/8 1n 1 SDR-21 I PVC
Corn Name :, 16.INNER CASING OR TUBING m eotheral closed-loop)
PAY - `• ':' I�l(„' FROM TO DIAMETER TIHCIINESS MATERAL
2.Well Construction Permit#: 22-265 n• ft. in
List all applicable well permits(1.e.County,State,Variance,Injecting eta)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DMfETER SLOT SIZE THICKNESS MATERIAL
ft. ft, in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. fL in.
❑IndustriaYCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 20 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑A uifer Storage and Recovery ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD
9 g rY tY ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPnON(color,hardne s soil/rock type,grain s6q etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It- 45 ft. Brown Dirt&Rock
4.Date Well(s)Completed: 2/20/23 Well EDP 45 fL 285 ft- Blue Rock
ft. fL
5n.Well Location: ft. ft.
Daniel&Katherine Beekman ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Sugar&Wine Rd, Marshville 28103 It. f� Seams:77',88',137',217',242'=10gpm,
276-2gpm
Physical Address,City,and Zip 21.RENIARKS
Union 01-135-003A
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/nduntes/seconds or decimal degrees: 22•Certification:
(ifwell field,one latllong is sufficient)
N W (,(�, r 3/1/23
Si tore ofCertified Well Contractol6l Date
6.Is(are)the we11(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(mere)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 ❑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 ofthis fore 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 b jection or iron-water supply wells ONLY with the same construction,you can
submit one fore SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 285 (M) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdiffereni(exannple-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 00 Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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 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 Mall Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 12 Method of test: Air 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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