GW1-2023-02656_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM, I TO DESCRIPTION
Well Contractor Name 133 1138 fe 2 9prn
4070-A 2023 154 ft1160 ft �3gpm (190-195'=3gpm)
15.OUTER CASING for 2 le
NC Well Contractor Certification Number FROM I TO M11.1,11
0 ft- 56 ft- 161/8 ir� I SDR-21 PVC
Derry's Well Drilling, Inc.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER THICKNESS MATERLiL
2.Well Construction Permit#: 22-414 ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) & ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL & in.
DAgricultural DMunicipal/Public . in.
ElGeothermal(Heating/Cooling Supply) 9111esidential Water Supply(single) ft ft
01ndustrial/Commercial DResidential Water Supply(shared) IS,GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 20 ft- Bentonite Pumped
ElMonitoring [:]Recovery Injection Well: ft. ft.
13Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(ifapplicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
OAquifer Storage and Recovery OSalinity Barrier ft. &
OAquifer Test OSiormwater Drainage
ft. ft.
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sollfrock type,Egn size,etc)
ElGeothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) 0 ft- 8 ft. Brown Dirt
4.Date Well(s)Completed- 1/26/23 We]IID# 8 ft- 16 ft. Brown Rock
16 ' & 285 ft- Slate
5a.Well Location: ft. ft.
Nicholas Hunter ft. fr: Seams:61',72',77',88',95', 112',
Facility/Owner Name Facility ID#(if applicable)
fL ft. 133-138'=2gpm, 154'=3gpm,190'=3gpm
2325 Ansonville Rd., Marshville 28103 ft. M
Physical Address,City,and Zip 21.REMARKS
Union 02167011
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutesAeconds or decimal degrees: 22.Certification:
(if well ficK one lat/long is sufficient)
N W 2/20/23
Signature-of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or []Temporary By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ENo copy of this record has been provided to the)veil oivner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back ofthis 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 ivells ONLY Ivilly the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple)veils list all depths j7differem(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply&Infection Wells
Also submit one copy of this form within 30 days of completion of
13b.Disinfection"e: 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
I I