GW1-2021-00779_Well Construction - GW1_20211208

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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. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 195 ft 205 ft 8 gpm
2465-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICIflVESS MATERIAL.
Derry's Well Drilling, Inc. o & 77 ft 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
289253 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 ❑MunicipaUPublic It. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft in
❑industriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 tt Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 tt 35 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soNroek 'e si2e,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)] 0 ft. 21 ft Red Dirt
4.Date Well(s)Completed: 10/22/21 Well ID# 21 ft 54 ft Brown Dirt
54 & 64 ft. Brown Rock
5a.Well Location: ft
Ricky Olomua 64 fL 340 ft ft �ue:Roi;K
Facility/Owner Name Facility ID#(if applicable) ft ft Seams:87�,9U',
1280 Crane View Rd., Salisbury 28146 ft ra
Physical Address,City,and Zip
21.REMARKS "'•.'._.
Rowan 612E012&028 " ' �'�;::riirt/l; >t%�.�.�E.I,�: t
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one IatAong is sufficient) ��/ �(/
N w9�� '^'• r'u��Il-u� 11/18/21
Si re of Certified Well Contractor Date
6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 EINo copy ofthis record has beenprovided to the:well 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
9.Total well depth below land surface: 340 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 ({t) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail 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
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) $ 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: 112 lb. well construction to the county health department of the county where
constructed.
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Form OW-1 North Carolina Department ofEnvironrnent and Natural Resources—Division of Water Resources Revised August 2013