GW1--07680_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , ;
14.WATER ZONES• I 1
Dwight L. Huneycutt FROM TO DESCRIPTION '
Well Contractor Name 73 ft. 75 ft. I •, 7 gpm
4070-A 90 ft 100 ft 1 ' 8 gpm
NC Well Contractor Certification Number IS.OUTEMCASING(for multi-cased wells)OR LINER(if ap IIcable) ,
' FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft- 61/8 SDR-21 ,PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop). _ '
22-304 FROM TO DIAMETER ' THICKNESS MATERIAL2.
2.Well Construction Permit#: ft. ft. is '
List all applicable well permits(i.e.County,State,Variance,Injection etc.)
ft. ft in.
3.Well Use(check well use): 17 g
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
IL ft in.
❑Agricultural ❑MunicipallPublic ,
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. in.
❑lndustrial/Comercial ❑Residential Water Supply(shared) 18.GROUT
in
FROM - TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 8 ft Bent.Chips Gravity
Non-Water Supply Well: ft. 2Q ft. Bentonite j Pumped
❑Monitoring ❑Recovery .
Injection Well: ft. ft. 1
❑Aquifer Recharge ❑Groundwater Remediation ,19.SAND/GRAVEL PACK(if applicable)'-.
FROM TO. MATERIAL j EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft }
❑Aquifer Test ❑Stormwater Drainage
f. fr. ,
❑Experimental Technology bSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
In Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)r 0 ft 22 ft Brown Dirt _
6/27/23 22 ft. 245 ft Slate
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
Dennis Spencer ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Bryte Ln, Marshville 28103 (River Hills, Lot 5) ft' ft. Seams:52',66',73'=7gpm,90'=8gpm,
ft. ft 99', 107', 119'
Physical Address,City,and Zip 21.REMARKS
Union 01-084-030 9 7—--'
County Parcel Identification No.(PIN) ....,3Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
•
�i�U 2023
(if well field,one lat4ong is sufficient) Z7�./--.. ri7et. ,F<; P-'I^=s^V,',, I IL-
N W 7/15/23; .,: :,;.•� �
Signature of Certified Well Contractor I Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 154 NCAC 02C.0100'or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 23No 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 i
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 i'
submit one form. SUBMITTAL INSTUCTIONS l' .
9.Total well depth below land surface: 245 (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100' construction to the following: ,
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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
t ,
15 Air 24c.For Water Supply&Injection Wells: '
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of •
13b.Disinfection type: Granular 1/2 lb. well construction to the county health department of the county where
Amount:
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013