GW1-2022-04305_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt F4.WATER ZONES
FROM TO DES ON
Well Contractor Name l�;;�' {'1 'i- i 95 R' 105 'L 20 gpm
4070-A ft.. fL
NC Well Contractor Certification Number APR 0 8 202? 15.OUTER CASING for multl-eased;wells OR LINER if a licable
FROM TO DIAMETER. THICKNESS MATERIAL
Derry's Well Drilling, Inc. �,.. r'j; '. 0 n 49 �• 61/8 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
P Y FROM TO DIAMETER MATERIAL
MATER
2.Well Construction Permit#: 21-145 fL & ;n
List all applicable well permits(i.e.County,State,Variance,Injection,etc) fL %
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public IL IL �
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) D' fL in-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 tti 3 fL Bent.Chips Gravity
❑Monitoring ❑R�my 3 fL35 a Bentonite Pumped
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a h'cable
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier & TO & MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/rock type,grain sim,ae
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 & 19 fL Brown Dirt Rock
12/13/21 19 fL 165 fL Slate
4.Date Well(s)Completed: Well ID# ft. fL
5a.Well Location: g• f,
Joseph &Stephanie Maus fL ft.
Facility/Owner Name Facility ID#(if applicable) fL
Cunningham Ln, Indian Trail 28079 � Seams:s5�,72�,s5�=2og
Physical Address,City,and Zip 21 REMARKS
Union 07018013A
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 �, Lt-,L., 1/20/22
Signature of C&dfied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 91No copy of this record has been provided 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 thisform. 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: 165 (g•) 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@100) construction to the following:
10.Static water level below top of casing: (ft.)
28 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 Injection 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.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013