GW1-2022-10021_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD !
For internal Use ONLY: � t
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt
14.WATER ZONES
John W. 4
FROM TO DESCRIPTION
Well Contractor Name ; 185
2465-A f4 190 fL 3 gpm
"' a r, k
ft. ft.
ry ,
NC Well Contractor Certification Number N O V 0 j Z022 15.OUTER CASING for multi casedwells"OR LINER if a licable
FROM TO DIAMETER I THICIQVESS MATERIAL
Derry's Well Drilling, Inc. _ Pmcaas�M Uric 0 ft' 147 ft- 6 1/8 itL SDR-21 PVC
16.INNER CASING OR TUBING eothermal closed-loop)
Company Name Jya fQ/30G :=.
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 326558 26558 8 ft.
List all applicable well permits ri.e.County,State,Variance,Injection,e1c.)
ft. fL 1;;in.
3.Well Use(check well use): tz SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublie ft ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft. is
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM _TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft, 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.`SAND/GRAVEL PACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
f4 ft. I
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional:sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(rotor,hardness,soilfrock type,grAin size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 1 0 ft- 12 fL Red Dirt
3/18/22 12 ft• 28 ft i; Brown Rock
4.Date Well(s)Completed: Well TD# 28 fL 265 ft• ' Blue Rock
Sa.Well Location: ft. ft.
Alice Honohan ft. fL
Facility/Owner Name Facility iD#(ifapplicable) j
ft. fL Seams: 50', 110', 120', 125', 154',
28214 Pole Running Rd., Mt. Pleasant 28124 rt. fL 185-1'90'=3gpm, 198',210',225',254'
Physical Address,City,and Zip 21.REDIARKS.
Stanly 139791
l:
County Parcel identification No.(PTN) !,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one IaUlong is sufficient) 4,Y/ ,
N w gq�& � ' _'� 3/29/22
Sign4YGre ofCcrtified Well Contractor V 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 15A NCAC 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 ❑No copy ojthts record has been provided to the'well mover.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under i.,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
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; I'
submit vie farm. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdirereni(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifirater 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
Rota 24a above, also submit a copy of this rm within 30 days of completion of well
12.Well construction method: Rotary construction to the following: 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
13a.Yield(gpm) 3 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 ofEnvironment and Natural Resources—Division of Water Resourcles Revised August 2013
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