GW1--07591_Well Construction - GW1_20231121

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WELL:CONSTRUCTION RECORD For Internal Use ONLY: '
- This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14..wATERZONEs I f'
9 Y FROM. TO DESCRIPTION
Well Contractor Name 109 ft 113 ft I ' 5 gpm
4070-A 132 ft- 140 ft 1 45 gpm
NC Well Contractor Certification Number •
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 52 ft- 61/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -- `
329535 FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) tL ft. in
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geotheal(Heating/Cooling Supply) DResidential Water Supply(single) ft.
in.rm
❑Industrial/Commercial ❑Residential Water Supply(shared) IS:GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 tr. 3 ft- Bent.Chips Gravity
. Non-Water Supply Well: •
❑Monitoring ❑kecovery 3 ft 20 ft Bentonite Pumped
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Injection Well: it ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)" . - -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test DStormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional'sheets if necessary) -' "'
❑Geothermal(Closed Loop) OTracer FROM TO - DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 rt. Red Clay
4.Date Well(s)Completed: 5/20/23 Well ID# 6 ft 15 ft. Brown Dirt
15 ' ft 145 ft ; Slate
5a.Well Location: ft. ft.
Phillip Wayne Harmon ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams:71',89', 109'=5g,132'=45g
28292 Hatley Farm Rd., Albemarle 28001 ft ft - • •
Physical Address,City,and Zip
21.REMARKS T ' tr-S: .,4 '.--"' '‘. .,- ..:)
Stanly 38131•
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County • Parcel Identification No.(PiN) N U�1 2 t 2`'23
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: US-CA
(if well field,one Iat/I 'ong is sufficient) 1 I tirvi; it r,', ',' r..-,'3
N W
1— . Gt,ZQ-u �Y i.6�10/23
Signature of ertified Well Contractor 1�/' Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By stirring this form I hereby certi&that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCACi02C.0200 Well.Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 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
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well.
For multiple wells list all depths ifdifferent(example-3@200'and 2(100) construction to the following: I
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter, 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: consWction 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
50 Air Mc.For Water Supply&InjectioniWells:
13a.Yield(gpm) Method of test:
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
If