GW1-2021-03214_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: €
DWIDwight L. Huneycutt F4.WATERZONES
9 Y FROM TO DESCRIPTION'
Well Contractor Name flo ft. 358 ft' i i 20 gpm
4070-A �� ��� 1. �gA ft.. ft.
NC Well Contractor Certification Number `) 15.OUTER CASING for multi cased wells OR LINER if a livable
�(O� \O FROM TO DIAMETER! THICKNESS MATERIAL
Derry's Well Drilling, Inc. �o� Sg o n• as ft• s 1/8 'in SDR-21 PVC
Company Name ( fV 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER' I THICKNESS .MATERIAL
2020011 W ���
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft' h• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 ft• Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑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 typt,Min sae etc.
❑Geothermal(Heatin Coolies Return) ❑Other(explain under#21 Remarks) 0 ft. 26 ft. Brown Dirt
8/10/20 26 f` 360 ff• Slate
4.Date Well(s)Completed: Well ID#
tt. tt.
5a.Well Location:
William Hallman tL tt.
Facility/Owner Name Facility IDS(if applicable) Seams: 72, 150,355=20g
311 Eighth St., New London 28127 (Pinehaven Lt 381)
Physical Address,City,and Zip 21.REMARKS
Montgomery 6663-12-964995,663-12-97-4066
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification;
(if well field,one]at/long is sufficient) 7C^J4(/
N W JO rV 7/30/20
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby'certifi'that the urll(s)icas(were)constructed in accordance
udrh 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Constratction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the ue//owner.
Ifthis is a repair,fill out known well constrttction information and explain the nature ofthe
repair tinder#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
S.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 some construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 360 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifiliferent(example-3@200'and 1C.100� construction to the following:
10.Static water level below top of casing: 15 (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection 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) 20 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.
f
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resotuces Revised August 2013