GW1-2023-01674_Well Construction - GW1_20230214

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WELL CONSTRUCTION.RECORD For Internal Use ONLY:
This foam can be used for single or multiple wells
1.Well Contractor Information;
Dwight L. Huneycutt r33
!ZONES t
g Y TO DESCRIPTION
Well Contractor Name ' R' 339 ' 'L I 5 gpm
r7 •�x,.! :r— �l !;" �`-``•teaft ft
4070-A �.��„;
_ TER TO
for multi cased wells 'OR LINER if a livable
NC Well Contractor Certification Number F�
^�^� FROM TO DIAMETER I' THICIUVESS MATERL►L
Derry's Well Drilling, Inc. L L o f� so 61/8 iI. SDR-21 PVC
Company Name16.i�rZ FROM ER CASDING OR TUBLIIHETER THl
ING hernra closed-loon)
MATERIAL
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2.Well Construction Permit#: 19-373 t "�,�a ft
List all applicable well permits(1.a County,State,Variance,Injection,eta)
& It: in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLIMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public -ft. ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FRi_.—
CAquiferTO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 03 ft- 'Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 320 ft Bentonite Pumped
Injection Well: ft
Recharge ❑Groundwater Remediation 19.SAD/ RAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sbeets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hordness,soitirock in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 22 ft Brown Dirt
12/6/22 22 ft 31 ft Brown Rock
4.Date Well(s)Completed: Well IDfE
31 ft 400 ft I' Slate
5a.Well Location: ft ft
Robinson Allen Eugene 9 ft. ft Seams:,67',76,88',93',97', 109%211%
Facility/Owner Name Facility Ilbi(if applicable) ft ft —
Jonah Ridge, Indian Trail 28079(Heritage Est. Lot 16) ft 333-339-' 5gpm
ft
Physical Address,City,and Zip 21.RENIARKS
Union 08-246-038
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W � G�JZO a/ 1/4/23
Signature of ertified Well Contractor V Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
with I5A 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 0No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this forme 23.Site diagram or additional well details:
You may use the back of this page to piovide additional well site details or well
S.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 forum. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 A) 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:
10.Static water level below top of casing: 43 (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
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 -
(Le.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) 5 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 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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