GW1--05075_Well Construction - GW1_20230804

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwl ht L. Hune cutt 14.WATERZONES "
g y FROM TO DESCRIPTION
Well Contractor Name 633 ft. 640 ft. 1 gpm
`"" e. ft. ft
'! I
4070-A P- t EZ
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if ap licable)
auG 0 2023 FROM TO • DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft* 48 ft. 6 1/8 in SDR-21 PVC
Company Name �,r� rt Ufi.X 16.INNER CASING OR TUBING(geothermal closed-loop)
202201 VV''i Sd. 1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: W fl +` '1OIG ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): , 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
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❑lndustrial/Commercial ❑Residential Water Supply(shared) 18. ROUT
FROMG TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑litigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier f. ' ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. •
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,soil/rock type,grain sire,etc)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 ft. Fill Dirt
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4.Date Well(s)Completed: 10/7/22 Well ID# 4 ft 22 ft Red Dirt
22 «• 38 ft. Brown Dirt
5a.Well Location: 38 ft. 770 rt. Slate
Maxwell &Amy Anthony ft. ft ,
Seams;72',75',96', 109',250',279',
Facility/Owner Name Facility ID#(if applicable)
169 Kingfisher Ct., New London 28127 fL 317',633'=1gpm,729'
Physical Address,City,and Zip 21.REMARKS
Montgomery 6662-05-29-3701
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) •
' L 10/25/22
N W
Signature of&rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(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: ❑Yes or ElNo 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 421 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
9.Total well depth below land surface: 770 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdfferent(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing: 65 (ft.) 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
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.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
1 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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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