GW1-2021-05874_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal use ONLY:
This form can be used for single or multiple wells
C
1.Well Contractor information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 254 ft. 258 ft. ! 6 gpm
2465-A ft. ft.
0 9 202�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifs licable
V L FROM I TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. SSin�Unit 0 ft. 44 ft- 6 1/8 SDR-21 I PVC
Company Name 10 -1 n 16.INNER CASING OR TUBING(geothermal closed-loop)
1 III l D�ni l�Sect o FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: 21 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
R. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLDTSIZE THICKNESS MATERIAL
ft. ft. I.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
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 2 lL
❑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 type,grain sla,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks 0 ft. 8 ft. Red Dirt
5/18/21 8 ft, 19 ft. Brown Dirt
4.Date Wells)Completed: Well iD# 19 ft 285 ft. Blue Rock
5a.Well Location: ft. ft
Guerrero Acosta ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. Seams:88',128', 156',210',254'=6g
4319 Jenkins Rd., Marshville 28103 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 03063013B
Comity Parcel Identification No.(PiN}
5b.Latitude and Longitude in degreeshWnutes/seconds or decimal degrees: 22.Certification:
(ifwell field one lat/long is sufficient) 6,b)
�� //
N w /� (ifi'. � 6/12/21
SiEolfure of Certified Well Contractor6f Date
6.is(are)the well(s): OPermanent or ❑Temporary Ay signing this farm,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 0N0 copy ofthis record has been provided to t&well owner_
ff this is a repair,fill our known well construction information and explain the nature of the
repair under e21 remarks section or on the back ofthis 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit rme form. SUBIIiTTTAL iNSTITCTiONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdoerenl(example-3 200 and 2 tr 100) construction to the following:
10.Static water level below top of casing 37 (ft.) Division of Water Resources,information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: 1n 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.]'field(gpm) 6 Method of test: Air
24c.For Water Supply At Injection IWells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. 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