GW1-2023-01607_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells II!
1.Well Contractor Information:
Derr�� L. Hune cuff 14.WATER ZONES
•J Y FROM TO DESCRIPTION
Well Contractor Name 515 ft 520 ft• 1 gpm
NC Well Contractor Certification Numbers !� h �� ° ° 15.OUTER CASING for mult i-cased wells OR LINER if a Gcable
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. ti 2023 o ft 46 ft 161/8 j,i" SDR-21 I PVC
Company Name A 16.INNER CASING OR TUBING eothermal closed-loon)
22—q 744 Pm`tz, r. (,rill FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 4rliucN��52C� • '••�°r�"�'•'� tr. fr. I'in. ,
List all applicable well permits ri.e.County,State,variances;jkclidi R f4 n j;in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well•_ FROM TO DIAMETER •i,SLOT SIZE THICKNESS M,4TERMLL
❑Agricultural ❑MunicipaUPublic ft & in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) % rt in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 a. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 tr. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: f. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licabk
EOf
TO MATERIAL; EMPLACEMENT AtETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. I,
❑Aquifer Test OStormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control
NG LOG attach additional'beets-if necessary)
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION(color,hardness,soiureck a sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 20 ft ;j Brown Dirt
11/17/22 600 'L Blue Rock
4.Date Well(s)Completed: Well ID#
ft.5a.Well Location: ft. Ii
RG Real Estate & fc Seams i 105', 112',156', 189',255',260%
Facility/Owner Name Facility ID#(if applicable)
7411 Lancaster Hwy, Waxhaw 28173 ftft. 295',390',515'=1gpm
Physical Address,City,and Zip 21.REMARKS
Union 05-020-001 G
County Parcel Identification No.(PIN) p
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wang is sufficient) 22.Certification:
N W D 12/5/22
Signature of fied Well Contractor Date
6.15(are)the well(s): ©Permanent or ❑Temporary By signing this forin.I hereby certify that the ivell(s)was(were)constructed in accordance
ivith ISA NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Stmn w-dv and that a
7.Is this a repair to an existing well: ❑Yes or IZJNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out(mown ivell construction`information and explain the nature ofthe I I
repair under#21 remarla section or on the back of thisform. 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 ONLPrvith the same construction,you can
submit one form. SUBMITTAL INSTUCPIONS i
9.Total well depth below land surface: 600 (ft) 24a. For All Wells: Submit this form'within 30 days of completion of well
For multiple wells list all de ila i di different 3 00'and 2 100 construction to the following:
P P f jf (example- Q2 @ � g:r
10.Static water level below top of casing: 75 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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: Rotary construction to the following:
(Le.auger,rotary,cable,direct push,etc.) 11.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1,636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Igiection W lhI
13a.Yield(gpm) 1 Method of test: Air Also submit one copy of this form w thIin 30 days of completion of
13b.Disinfectiantype: Granular Amount: 1/2 lb. well construction to the county health department of the countywhere
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resouit Revised August 2013
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