GW1--05145_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Corm can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER/ANES
FROM TO DESCRIPTION
Well Contractor Name 85 ft. 92 tt• 5 gpm
4070-A 155 ft* 158 ft. 20 gpm
NC Well Contractor Certification Number IS.OUTER C%SING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 50 ft. 61/8 in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
CHA-WE-2024-00090 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 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 SI7E THICKNESS MATERIAL
fG ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. _
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lnigation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recoven 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquiter Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. fr.
L Expert mental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION(color.hardness.soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 ft. 4 ft. Brown Dirt
7/5/24 4 ft• 31 ft. Brown Granite
4.Date Well(s)Completed: Well ID#
31 ft• 43 ft Junky Blue Granite
5a.Well Location: 43 ft: 185 ft• Blue Granite
Hayden Scott Carroll ft. ft.
FacilitsOwner Name Facility IDn(if applicable) ft. ft.
Seams:58',72',85'=5g, 155-158'=20g
7777 Grateful PI, Concord 28025
ft. ft. a•. ;
physical Address,City and Zip 21.REMARKS a ♦ j,
Cabarrus AUG' of' 0 Z024
(linty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: D,a•.- .. �'�-•� ''
(tfwell field one IatAong is sufficient) y,;l..•._to
N V, 7/10/24
Signattue of ertified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary Iiy signing this firm.I hereby certify that the wellls)was(imo constructed in accordance
with 1SA N('A('02('.0100 or IS9 N('AC 02('.0200 Well('instruction Standards and that a
7.Is this a repair to an a:isting well: ❑Yes or Inio copy of this record has been provided to the well owner.
If this is a repair.Jill out known well construction information and explain the nature of the
repair farrier,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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply Hells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lot all depths iJ dillerent leuimpie-7/ii 200'and ii)1011) construction to the following.
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit.
4 H aver level it()hove eating,ore .. 1617 Mail Service Center,Raleigh.NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection 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
lie 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) 25 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