GW1--07695_Well Construction - GW1_20231122

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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:
John W. Hune cuff 14.WATERZONES '.
Y FROM TO DESCRIPTION '
Well Contractor Name 170 ft 175 ft I 2 gpm
2465-A 256 ft 260 ft• 8 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licahle)
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft• 61/8 ir,,• SDR-21 PVC
•
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-554 FROM TO DIAMETER I' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(1.e.County,State,Variance,Injection,etc.)" ft ft iry
3.Well Use(check well use): 17.SCREEN `
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural ❑Municipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18'GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent.Chips• Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 f Bentonite I • 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 ❑Stonnwater 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 size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 ft Brown Dirt
4.Date Well(s)Completed: 9/18/23 Well #ID 15 ft 35 ft. Brown Rock
35 ft 265 ft• i . Blue Rock
5a.Well Location: ft ft. '
Matthew&Megan Kimball ft ft I.
l acility/Owner Name Facility ID//(if applicable)
5512 Cane Creek Rd., Waxhaw 28173 ft: ft Seams:,56',65, 100, 135, 145, 170=2g
ft ft. 205-210',216',256'=8gpm .
Physical Address,City,and Zip 21.REMARKS
Union 05027001G r '�, T-
e
County Parcel Identification No.(PIN) •
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification U V 2 2 2023
(if well field,one lat/long is sufficient)
�u� Inr.:',4'0/9/23 7r�. r.^,_a_?ac, i
N W l s;:?
Si a of Certified Well Contractor Date i''`,``...; 1-U2j
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DNo copy of this record has been provided to the vell 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 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 1 -
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifscaler level is above casing,use"+" 1617 Matz 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
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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(gpm) 10 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 OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013