GW1--02721_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1 '
This form can be used for single or multiple wells 1
1 •
1.Well Contractor Information: ,
JohnHuneycutt 14.WATER ZONES i'
W.
FROM TO DESCRIPTION
Well Contractor Name 108 ft- 112 ft- I I 1 gpm
2465-A 278 ft- 287 ft- I 2 gpm
NC Well Contractor Certification Number 15.OUTER R CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft- 6 1/8 i ' in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
402040 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. 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 in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
' ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft 10 ft. Brown Shgl,
4/1/24 10 ft- 420 rut. Slate �': 4,a.",,1 a' a F.1
4.Date Well(s)Completed: Well ID# ! fi
ft. ft. ,
5a.Well Location: ft. ft. !t,'.4:::1AYa --77
�l�t?
lrPfairr= .,;;;�,-_, a
Facility/Owner Name Facility ID#(if applicable) V td, '." v'^�
Michael Gatien ft. ft. i
'
ft. ft. Seams:72',90',96', 108'=1 g, 116 ';`, $
16123 Silver Rd, Oakboro 28129 ft. ft• 235',278-287'=2g,312',331',349',367'
Physical Address,City,and Zip
21.REMARKS
Stanly 142255
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 W 4/12/24
Sign of Certified Well Contractor!' Date
1
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCi1C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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
9.Total well depth below land surface: 420 (ft.) 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@I00) construction to the following:
10.Static water level below top of casing: 30 (ft.) 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 Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following: d '
(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
3 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 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 WaterlReisources Revised August 2013