GW1-2021-01779_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: lre�
Dwight L. Huneycutt 14.WATER ZONES
FROM TO I DESCRIPTION,
Well Contractor Name �O rt. 358 ft' 20 gpm
NC Well Contractor Certification Number ``)) 15.OUTER CASING for multi-cased wells OR LINER if o lieable
A(O� \0 FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. a� 58 o ft• 46 f` 16 vs i° SDR-21 PVC
Company Name Q 16.INNER CASING OR TUBING(geothermal closed400
FROM TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit#: 2020011 W VP tt. tt. in.
List all applicable well permits(i.e.Count)-,State,Variance,Injection,etc.)
ft. ft. Iin•
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft k' in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f` 20 ft Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. fG
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,grain sirA etc.
OGeothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) 0 rL 26 ft. Brown Dirt
8/10/20 26 f` 360 ft• Slate
4.Date Well(s)Completed: Well ID#
rt. ft.
5a.Well Location:
William Hallman
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams: 72', 150',355'=20g
311 Eighth St., New London 28127 (Pinehaven Lt 381) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Montgomery 6663-12-96-4995,663-12-97-4066
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaVlong is sufficient)
N W JOV 7/30/20
Signature of Certified Well Contractor V Date
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6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this form,I hereby certify that(the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or END copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nahtre of the
repair tinder#21 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 wells ONLP ivith the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-305,200'and 2@100� construction to the following:
10.Static water level below top of casing: 15 tft•) Division of Water Resources,Information Processing Unit,
If water 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
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) 20 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013