GW1-2021-05827_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
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1.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES
� - FROM TO DESCRIPTION
Well Contractor Namc 55 ft 65 ft. 25 gpm
4070-A �UL 0 202 fr fr
NC Well Contractor Certification Number procegs��� _TER CASING for multi cased wells OR LINER if a livable
PROM TO DIAMETER THICKNESS I MATERIAL
Derry's Well Drilling, Inc. tQC�;atlo ��e;Von o ft. 28 ft. s v8 SDR-21 PVC
Company Name —� 16.INNER CASING OR TUBING(geothermal closed-loo
2018-00000891 FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. fr. in.
List all applicable well permits f.e.County,State,variance,lttjeclion,etc.)
ft. ft. in
3.Well Use(check well use): 17.SCREEN
Rater Supply Well: FROM TO DIAMETER SLOTS17JE THICKNESS MATERIAL
ft. fL in.
OAericultural ❑Municipal/Pubhc
❑Geothermal(Heating/Cooiing Supply) OResidential Water Supply(single) ft. ft. in'
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 it• 3 tL 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 Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMIIVTAfETHOD
CL fL
❑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.soillrock tym grain si2e,efe
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 6 ft Wet Brown Clay
4/3/21 6 ft. 15 ft. Brown Dirt
4.Date Well(s)Completed: Well iD# 15 ft 125 ft• Blue Granite
5a.Well Location: ft. tt
Lindsey Angel ft. ft
Facility/Owner Name Facility ID#(if applicable)
it. ft .Seams:38',47',55'=25gpm
2929 Mammie May Rd., Franklinville 27248 ft. &
Physical Address,City,and Zip 21.REMARKS
Randolph 7786202388
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22-Certification:
Orwell field,one lat/long is sufficient)
N `,1, 4/29/21
Signature o Certified Well Contractor Daze
6.Is(are)the well(s): OPermanent or ❑Temporary
Ay signing this form,/hereby certify that the well(s)was(trere)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: ❑Yes or E]No copy afthis retard hat been provided to the well owner
If this is a repair,fill out known well construction information and explain the nature of fhe
repair under ft21 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 provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Nor multiple injection or non-wafer supply wells ONLY with the same construction,you can
submit one form SUBMITTAL TNSTUCTiONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this:form within 30 days of completion of well
Nor multiple wells list all depths ifdii fereni(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 19 (ft,) Division of Water Resources,information Processing Unit,
Ifsvater level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: lin 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: r
(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) 25 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 Mount, 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 I Revised August 1013
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