GW1-2022-04361_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: y—,
�: 3^ 14.WATER ZONES
John W. Huneycutt
FROM TO DESCRIPTION
Well Contractor Name q P R 11 2022 172 fL 177 ft• 8 gpm
2465-A ft. ft.
NC Well Contractor Certification Number r�' ? f'r% 15.OUTER CAS iNC for multi-cased wells OR LINER if a licable
V�'•`r,•� I'li'k� FROM TO DIAMETER TffiC[flVFS.S MATERIAL
Derry's Well Drilling, Inc., r o ft 44 ft 6 v8 1 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
353576 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. t[. is
List all applicable well permits(i.e.County,State,11arlance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft is
❑industriaUCommercial ❑Residential Water Supply(shared) i&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri tion 0 ri' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 fl- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fL [L
❑Aquifer Test ❑Stormwater Drainage
CL CL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attech additional sheets it ner
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,haNness,seWrock#yM grainsize etc
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) 0 ft 8 fL Sand
5/26/21 8 ft. 34 ft. Cobblestone
4.Date Well(s)Completed: Well TDk
34 fL 185 ft. Granite
5a.Well Location: ft. ft.
Darian D. Lampley ft. tL
Facility/Owner Name Facility W4(ifapplicable) fL t0 Seams: 65',78', 114', 136', 172'=8g
1171 US 1 S, Rockingham 28379 fL ft.
Physical Address,City,and Zip 21.REMARKS
Richmond 745000281668
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) ����
N N, � W//. ��'�� 6/15/21
Si ure ot'Certitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By,signing this farm.I herehy certify that the well(s)uns(were)constructed in accordance
with 15A NC AC 02C.0100 or 15A N:AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well ruiner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under ii2l remarks.section or on the back ojthis 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.
har multiple injection or non-water supply wells ONLY with the same construction,you can
submit one foam. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 185 (p.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ij doereni(example-3(200'and 2Q100') construction to the following:
10.Static water level below top of casing, 34 00 Division of Water Resources,Information Processing Unit,
Ifwater 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 construction to the following:
24a above, also submit a copy of this form within 30 days of completion of well
N 12. ell construction method: g: I
(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
P
24c.For Water Supply&Injection)yells:
13a.Yield(gpm) 8 Method of test: Air 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