GW1-2023-02645_Well Construction - GW1_20230411

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
John W. 1 uneycutt FROM TO I DESCRIPTION
Well Contractor Name 328 ft 335 ft. I
3 gpm
2465-A ft 388 1395 ft- 1 gpm
NC Well Contractor Certification Number 15,OUTER CASING for THI_wells l P LINER 11apycable,
_ L
FROM I TO TT=,S, I MATERIAL
Derry's Well Drilling, Inc. APR 2023 0 ft 145 ft 16 1/8 '- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR RING(geothermal closed-imp)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 19-233 ft ft. in.
List all applicable well permits(l.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 THICKNESS MATERIAL
OAgricultural 13MunicipaVPublic ft ft. in.
DGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) It- ft. i.
01ndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrriggion 0 fL 3 ft Bent.Chips Gravity
Non-Water Supply Well:
13Monitoring ORecovery 3 ft 20 fi- Bentonite Pumped
Injection Well: H M
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ElSalinity Barrier ft. ft.
OAquifer Test OStormwater Drainage ft. it. I
ElExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necc I ssary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(calor,hardnem,sail/mck type,grOn sbT.etc.)
[]Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) 0 ft. 10 ft. Red Dirt
4.Date Well(s)Completed: 3/10/23 Well ID# -- 10 ft 30 ft. Brown Dirt
30 fit- 445 ft- Blue Rock
So.Well Location: ft. ft.
Tim Richardson It. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft fX Seams: 100'.160',260',328'=3gpm,
237 Barra Dr.,Waxhaw 28173 (Aubert Landing Lt 7) —f, ft. 388'=Igpm
Physical Address,City,and Zip 21.REMARKS
Union 05-039-096
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/smonds or decimal degrees: 22.Certification:
(ifwcU field,one Wong is sufficient)N —W QiZ& a' 4/5/23
•
Sig(Xurc of Certified Well Contractor Date
6.Is(are)the well(a): OPermanent or OTemporary 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: OYes or E)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 921 remark 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.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple ii#ection or non-water supply wells ONLY with the same construction,you can
submit one foral. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths it'different(example-3(200'and 2@ 100) construction to the following:
10.Static water level below top of casing- 45 — Division of Water Resources,Information Processing Unit
lfwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 24b.For Inlection Wells ONLY. In addition to sending the form to the address in
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 27699-1636
13a.Yield(gpni) 4 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b Granular Amount: 1/2 lb. well construction to the county health department of the county where
,Disinfection type. constructed.
Form GW-I North Carolina Department ofEnviroament and Natural Resources—Division of Water Resources Revised August 2013