GW1-2022-04285_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name gpm
388 "- 395 &
2465-A APR 0 ft. — ft.
NC Well Contractor Certification Number 15.0'UTIERC TEG,(lurTRI LINER if
DIAMETER THI MATERIAL
1
Derry's Well Drilling, Inc. f' 61/8 0 ft- 146 SDR-21 PVC
Company Name
16.INNER CASING OR TUBING(mthn-mal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 21-345 ft. ft. In.
List all applicable well permits(1.e.County,State,Variance,Injection,etc.) ft. it. in.
3.Well Use(check well use); 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural [:]Municipal/Public ft. ft.
CGeothermal(Heating/Cooling Supply) k]Residential Water Supply(single) ft• ft. in.
01ndustrial/Commercial GResidentiall Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ElTrrigation 0 ft 3 fL Bent Chips Gravity
Non-Water Supply Well:
DMonitoring DRecovcry 3 ft- 35 fL Bentonite Pumped
J[Wjection Well: ft. ft
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACKfifarnIt'cable
)
FROM TO MATERIAL I EMPLACEMENT METHOD
DAquifer Storage and Recovery D Salinity Barrier ft. ft.
OAquifer Test OStormwater Drainage ft. ft.
DExpertmental Technology OSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,haWrms,saitfrockilype,grain sh"etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 10 ft Brown Dirt
4.Date Well(s)Completed: 12/31/21 Well MM 10 ` 22 ft Brown Rock
22 fr- 540 ft- Slate
5a.Well Location: ft. ft
Christopher Morris rt. It.Fac I
ility/OwnerName facility lD#(if applicable) ft it. Seams: 54',70', 113', 170', 181', 193',
6017 Griffith Rd, Monroe 28112 ft. ft. 206',235',368',380',388'=Igpm
Physical Address,City,and Zip 21.REMARKS
Union 04279032M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latilong is sufficient)
N WW.
1/18/22
Sign 66m ofCertificd Well Contractor V! Date
6.Is(are)the well(s): OPermanent or 07remporary
By signing this form. I hereby cer*that the well(s)was(were)constmcied in accordance
with 15A NCAC 02C.0100 or 15A NC4C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: C]Yes or ElNo copy of this record has been provided to the well miner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under..21 remark 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one fo— SUBMITTAL INST11CITONS
9.Total well depth below land surface: 540 (ft.) 24a. For All Wells.- Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdifferent(example-3@200'and 2@10ff) construction to the following:
10.Static water level below top of casing: 85 (fL) Division of Water Resources,Information Processing Unit,
lf-irater level is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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:
(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 pwithin 30 days of completion of
13b.Disinfection type-. Granular Amount. 1/2 lb. well construction to the county healthdepartment of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013