GW1--02771_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt ._, il z r 14.WATER ZONES
(• , 4 Y;��f.,n,1 FROM TO DESCRIPTION
Well Contractor Name 58 60 I1gpm (110-125'=1 gpm)
2465-A MAY Co 7 2024 208 it 218 ft • I 1 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wellsj OR LINER(if ap licahle)
iris nw:?*.rP. 7'7'.r.ir,".::=;3}j-r# FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. r.;o'(;c'no,o o ft 45 ft 6 1/8 ( is SDR-21 PVC
Company Name . 16.INNER CASING OR TUBING(geothermal closed-loop)
23-381 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. H. I in.
List all applicable well permits(i.e.County,State,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. in ft. ,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soihrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft 1 Brown Dirt
4.Date Well(s)Completed: 2/17/24 Well ID# 25 ft- 305 ft j Slate
ft ft. I!
5a.Well Location: ft ft
Eden Custom Homes LLC
ft. ft Seams:50',55',58'=1g, 110'=1g, 130',
Facility/Owner Name Facility ID#(if applicable) ft. ft �_3g,225',
6311 Hwy 205, Marshville 28103 (New Salem Est., Lt 6) 140, 154,185,208-2240',
Physical Address,City,and Zip ft. ft 250',258—8'
21.REMARKS
Union 01-144-012H
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: j
(if well field,one lat/long is sufficient) � � � / i
N W ram('/ 3/10/24
Si lure of Certified Well Contractor 1 Date
6.Is(are)the well(s): l22lPernranent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 1SA 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 DNo 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 j
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdi( erent(example-3@200'and 2®100') construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Res nrces,Information Processing Unit,
Ifwater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: f 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,IUrlderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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 of Environment and Natural Resources—Division of Water Resources Revised August 2013
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