GW1-2021-01782_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY. f
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune cutt °� 14.WATERZONES
g Y FROM TO DESCRIPTION
Well Contractor Name rtIVI 11 ff 120 ft' 12 gpm
4070-A 9 ft. ft. I
NC Well Contractor Certification Number J�)� 5\� 15.OUTER CASING for multi cased wells OR LAYER if a licsble
P.0 �QQ� FROM TO DIAMETERI THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,Q�Q CjP+�' 0 ft. 45 ft 6 1/8 'i" 1 SDR-21 I PVC
Company (Z• 16.INNER CASING OR TUBING eotherroa]closed400
P y Name 2019013W ���` O FROM TO DIAMETER! THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL in.
List all applicable well permits(i.e.Count)-,State,Variance,Injection,etc.)
ft. ft. jin.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER ISLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fa in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL[ EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 «' 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnns soil/rock type,grzin sim etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks 0 H- 13 ft. Brown Dirt Rock
7/10/20 13 ft. 165 H- Slate
4.Date Well(s)Completed: Well ID#
tt. tt.
59.Well Location:
Dana F. McNeill ft. ft.
Facility/Owner Name Facility 1134(if applicable)
135 Third Ave., New London «. ft. Seams: 48',52',55',78',90', 11V=12g
rL ft.
Physical Address,City,and Zip 21.REMARKS
Montgomery 663-08-88-9606
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient) /
N W 7/30/20
Signature of ertiftcd Well Contractor IV Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ell(s).vas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 0 u2C.0200(fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E3No copy of this record has been provided to theli ell oumer.
Ifthis is a repair,fill out knour well construction information and erplain the nature of the
repair tinder#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 kith the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
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10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ifuater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: Inv addition to sending the form to the address in
Rota 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
m 13a.Yield
(gp ) 12 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources ± Revised August 2013
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