GW1--05077_Well Construction - GW1_20230804

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
9 Y FROM TO DESCRIPTION
Well Contractor Name 75 ft. 83 ft. 5 gpm _ _
4070-A 214 ft. 220 ft. 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)Ott LINER(if ap licable)
FROM TO DIAMETER _ THICKNESS MATERIAL _
Derry's Well Drilling, Inc. p ft. 49 ft. 6 1/8 • in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#:
2023002W(Variance#WWM1538) s FROM-ft. TO ft DIAMETER in. THICKNESS MATERIAL
iist 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) ❑Residential Water Supply(single) tt• ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
_ FROM TO . MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigation n "�v:t ' ft ft.
Non-Water Supply Well: t %a e ti... �i 0 3 Bent.Chips Gravity —
❑Monitorin ❑Recove 3 ft, 49 ft. Bentonite Pumped
Injection Well: ry AUG kit _ Zoi� ft. ft.
❑Aquifer Recharge ❑Groundwater Reme4iatiox .w19.SAND/GRAVEL PACK(if applicable) -.
yw'1 n ti ~ FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑SalffliffBameDwohsoG ft. ft
❑Aquifer Test ❑Stormwater Drainage - -
ft. ft.
❑Experimental Technology 17 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/melt type.grain size.de.) -
❑Geothennal(Heating/Cooling Return) ❑Other(explain underI/21 Remarks) 0 ft. 13 ft. Red Dirt
2/20/23 13 ft 245 ft Slate
4.Date Well(s)Completed: Well ID# - ft. ft.
5a.Well Location: ft. ft.
Stephen Skipper - ft. ct
Seams:55',67',75—5gpm, 148',
FacilitylOwner Name Facility ID#(if applicable)
ft. ft. 214'=3gpm
Blaine Rd., New London 28127 ft ft.
Physical Address,City,and Zip 21,REMARKS - -.
Montgomery 6673-11-65-9709
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/long is sufficient)
N W 72GtiL. 3/31/23
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(I2C.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=11 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: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
,For multiple wells list all depths ifdijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 28 (a) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In 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: ry 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 m 8 Method of test: Air 24a For Water Supply&Injection Wells:
(gpm) 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