GW1-2021-00842_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:
Huneycutt 14.WATER ZONES
John W. HUne
Y FROM TO DESCRIPTION
Weft Contractor Name 159 n' 165 n' 2 gpm
2465-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER a Rcable
FROM TO DIADtETER 17HCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 n 43 fL 161/8 in I SDR-21 I PVC
Company Nam 16.INNER CASING OR TUBING(geothermal closed-loop)
21-13 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n. n. ►n.
List a0 applicable well permits(i.e.County,State,Variance,Injection,etc.)
In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMTER SLOT SITE TTHCKNESS AATERIAL
n. ft. �•
❑Agricultural ❑Municipal/Public
❑Geotheral(Heating/Cooling Supply) ®Residential Water Supply(single) n n in.
m
❑lndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FRODf TO MATEERIAU ENIPLACENIENT METHOD&ADIOUNf
OlnigatiNon-Water r Supply Well: 0 n• 3 n• Bent.Chips Gravity
❑Monitoring ❑Recovery 3 n 35 Bentonite Pumped
Injection Well: n. n.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
� n•
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addltionafsheets itnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc
❑Geothermal(HeatingtCooling Return) ❑Other(explain under#21 Remarks 0 n 23 n Brown Dirt&Rock
4.Date Well(s)Completed: 7/17/21 well ID# 23 f' 500 n• Blue Rock
n. n.
5a.Well Location: n. ft.
Ronald Yow
Facifity/Owner Name Facility ID#(if applicable) r -
59'i 2g',
n. n. ' !
618 North Forest Hills School Rd.,Marshville 28103(Boyce Phifer Est.) Seams:85', 115', 125','b6', 1`
n. n.Physical Address,
275',365',3fPF r1,City,and Zip 21 REMARKS
Union 02208007E
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 �& (�{/ Y�iura. 8/11/21
Si of Certified Well Contractor Date
6.Is(are)the weil(s): 1OPermanent or ❑Temporary By signing this form,I hereby certify that the evell(s)was(ivere)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?]No copy of this record has been provided to the well omvner.
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
&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,your can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 52 (g•) Division of Water Resources,Information Processing Unit,
if,vater 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
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) 2 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fora 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.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
C
i
i