GW1--05040_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hume cuff 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name (�,; 1/`"'�,+'^I? •^r'.4 110 ft- 115 ft- 5 gpm
2465-A t !. ` 'i ` --P' 230 ft 235 ft 5 gpm
NC Well Contractor Certification Number A U G 0 A 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 45 ft 61/8 in. SDR-21 PVC
Corn Name It,$.,,•'-;%. , ,;,t..,gcg tit t; 16.INNER CASING OR TUBING(geothermal closed-loop)
y 19-231 D P 'J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply) 21Residential Water Supply(single) it ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft ft
3 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft- 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sine,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft Brown Dirt&Rock
4.Date Well(s)Completed: 2/27/23 Well ID# 25 ft- 345 ft Blue Rock
ft ft.
5a.Well Location: ft. ft.
Tim Richardson
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams:50-50',80', 110'=5gpm, 121',
ft. ft. 171', 185',210',230'=5gpm,268'
Barra Dr., Waxhaw 28173 (Aubert Landing, Lot 3) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 05-039-092
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) '',, ll
N `i, �8/ W. 3/15/23
Sign e of Certified Well Contractor Date
6.Is(are)the well(s): 127Permanent or DTemporary By signing this form,1 hereby cert fy that the wells)was(were)constructed in accordance
with 1SA 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 of this record has been provided to the well owner.
If this is a repair,fill out known well construction Information mid explain the nature of the
repair under#21 remarks 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
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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd/Jerent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 38 (ft) Division of Water Resources,Information Processing Unit,
Ifseater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.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(gpm) 1 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013