GW1-2021-00833_Well Construction - GW1_20211208

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.WATERZONES
Y FROM . TO DESCRIPTION
Well Contractor Name 359 n• 365 ft. M 1 gpm
2465-A R• M
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased g OR LINER applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Denys Well Drilling, Inc. 0 n 191 n• 6 1/8 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
21-179 FROM TO DIAMEM THICENFSS MATERIAL
2.Well Construction Permit#: R. tt. [m.
List all applicable cell permits(i.e.County,State,Variance,Injection,etc)
fr. fL la.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public it. I fr. m.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) D D
❑ludustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 n• 3 it- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it- 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK a Ticsble
FROM TO I MATERIAL I EMPLACEMENT r*WMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. rt.
❑Aquifer Test ❑Stormwater Drainage
tit. fL
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,baton solyrock type etc)
❑Geothermal(Heating/Cooling Return ❑Other lain under#21 Remarks 0 it 16 n Red Dirt
7/31/21 16 ft. 30 it• Brown Dirt
4.Date Well(s)Completed: Well 1D#
30 n 64 h Brown Rock
5a.Well Location:
64
Pinnacle Homes USA, LLC n R. ti ao0 ft., Blue Rock
Facility(Otvrer Name Facility ID#(if applicable)
u. it• Seams: 185',194',
6201 Philadelphia Church Rd., Marshville 28103 e. ft. -
370
Physical Address,City,and zip 21.REMARKS
Union 03-111-009A
County Parcel Identification No.(PIN) (,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W �& a) 8/13/21
Si of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,7 hereby certify that the tvell(s)uos(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to the well owner.
If this is a repair,fill ors known ivell construction information and ctplain the nature of the
repair tinder#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use die 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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• 400 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
lfutter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In 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:
(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) 1 Method of test: Air 24c.For Water Supply&Iniection Wells:
Also submit one copy of this forin 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.
i
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

DERRY'S WELL DRILLING, INC.
_ . . 44283-A.Hwy. 24-27
Albemarle, N.G.28001. ,. ,
- Phone(704)`982=3070 • Fax [phone]