GW1-2023-01671_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells j
1.Well Contractor Information:
Der L. Hume cuff 14.�WATERZONES,
rY Y FROM TO DESCRIPTION 1
Well Contractor Name h 175 fL 180 ft I I 2 gpm
2663-A "_ '' ���' 290 ft 300 ft 6 m
n 9p
NC Well Contactor Certification Number FEB
.15.OUTER CASING for multi-eased wells OR LINER if a licable
FROM TO DIAMETER I TMCKNF55 MATERLUL
Derry's Well Drilling, Inc. _ 2023 o ft 45 ff 61/8 SDR-21 I PVC
Company Name lfir;,r7%?aye t�Tti ?u��".' r `-FROMNER CASING OR TUBING
(geeoth i rural cllorseed FS5 MATERIAL
22-305 ulyb't�'. , l rtP
2.Well Construction Permit#: mi 1, ft ft. I io
List all applicable well permits(i.e.County,State,Variance,Injectio),etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN, :.
Water Supply well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in j
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft is ji
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ts.GROUT f
FROM TO MATERIAL EMPLACEMENT METHOD&AMOnNT
❑Irri ation 0 ft 3 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 n Bentonite', Pumped
Injection Well: ft ft
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if auriticabI6.
FROM TO NATERIAL i EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft I,
❑Aquifer Test ❑Stormwater Drainage
ft, ft 1 I
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional si cets if necessary)'-
[]Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soNrock six,etc.
❑Geothermal(Heating/Cooling Return) ❑other explain under#21 Remarks 0 0• 12 & Brown Dirt
4•Date Well(s)Completed: 10/20/22 Well ID# 12 ft 325 ft ';• Blue Rock
f4 ft
5a,Well Location: ft it
Joe &Maggie Saturle
99 Y ft ft c
Facility/Owner Name Facility ID#(if applicable)
7012 Ashe Ln, Waxhaw 28173 It. ft Seams:95', 150', 175'=2gpm, 187', 197',
ft ft 2100216',230',245',290'=6gpm
Physical Address,City,and Zip 21 REMARKS -
Union 04-347-021
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) Z�'N W
Z'�/L I, 11/15/22
Signature of rtified Well Contractor V {; Date
6.1s(are)the well(s): OPermanent or ❑Temporary By signing flits forax I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well aivner.
If this is a repair,fill our known well construction information and explain the nature of the l'
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to piovide 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 ONLY with the same construction,you can I
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this forr'n within 30 days of completion of well
For multiple wells list all depths tfd fferem(example-3@200'and 2@100) construction to the following:
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36 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (tt.) ,
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this 1;foim within 30 days of completion of well
12.Well construction method: constntction to the following:
(i.e.auger,rotary,cable,direct posh,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cente,Raleigh,NC 276994636
13a.Yield(gpm) 8 Method of test: 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.
Form GW-1 North Carolina Department of Environnu;ut and Natural Resources—Division of Water Resources Revised August 2013