GW1--02710_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: '
Huneycutt 14.WATER ZONES
1
John W. HUne
Y FROM TO DESCRIPTION
Well Contractor Name 98 a 102 a 3 gpm (178-185'=2 gpm)
2465-A 565 a 570 ft I I 7 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER . THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 97 ft 6 1/8 !,16. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
#4 FROM TO , DIAMETER THICKNESS MATERIAL
41238
2.Well Construction Permit#: � ft. ft. . in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I7JAgricultural ❑MunicipallPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rr. 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(i(applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StormwaterDrainage g ft
❑Experimental Technology 0 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 d21 Remarks) 0 ft. 60 ft Red Dirt
7/4/23 60 ft 90 ft Brown Dirt&Rock
4.Date Well(s)Completed: Well D?#
90 It 525 ft. PBlue Rock
5a.Well Location: 525 a 600 ft ! Pink Granite
Patrick Robinson ft ft.
Seams:98'=3g,148', 152', 178-2g, 190',
Facility/Owner Name Facility ID#(if applicable) ft. ft- 267',317',330',350',357',447',465',
529 Mt. Carmel Rd, Carthage 28327 ft. ft
470',488',515',525',547',565'=7g,575'
Physical Address,City,and Zip 21.REMARKS
Moore 00009793 rp -1 Y-• ,
County Parcel Identification No.(PIN) I ! ` ' ".. i."'v k, C,—�+w_,r'
sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: MAY U 1
22.Certification: t G24
(if well field,one lot/long is sufficient) // �
N W - ^,-1 Pr,c sxc; 1,4/2
Si a of Certified Well Contractor Eng1..Yr3O(Date
6.Is(are)the well(s): iZ7Permanent or ❑Temporary By signing this form,I hereby cert)"that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or iSA NCAC;02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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
1
9.Total well depth below land surface: 600 (ft.) 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 2Q100) construction to the following:
10.Static water level below top of casing: 30 (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 (in.) 24b.For infection 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:
(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) 12 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this fon i 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. 1}
II
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013