GW1--05081_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 FROATERZ OAS DESCRIPTION
Well Contractor Name 75 it, 85 ft. 1 5 gpm
4070-A 132 n 139 ft. 30 gpm
NC Well Contractor Certification Nurnlvr 15.OUTER CASING(for multi-cased wells)OR-LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 52 ft. 6 1/8 in• SDR-21 j PVC
Company Name -WANNER CASING OR TUBiNG.(¢eothermal closed-loop) .
2022027W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
fist 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) ft. . ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD$4.AMOUNT
❑Irrigation 0 ft• 3 ft, Bent.Chips Gravity •
Non-Water Supply Well: —
[Monitoring ❑Rea overy 3 ft. 20 ft• Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK(if applicable)-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soillrock type,grain size,etc.)
❑Geothennal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 4 ft. Red Dirt
4.Date Well(s)Completed: 2/16/23 Well ID# 4 ft. 17 ft. Wet Red Clay
17 ft• 165 ft• Slate
5a.Well Location: ft. ft.
Stephen Skipper ft. ,
Seams:55',63',69',75'=5gpm,
-5gprn,
Facility/Owner Name Facility ID#(if applicable) ft. ft
775 Blaine Rd., New London28127 132'=30gpm
ft.
Physical Address,City,and Zip 21.REMARKS r�. + ••,t' i t w .i •,^-1
Montgomery 6673-11-65-9709 t z A. I..:‘ v c LE
County Parcel identification No.(PiN) x h l i r►] 02023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lalllongissufficient) info;f7 ,yftn 7r;•-: ,.g Ur.
N W v L( L iW
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 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ts 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 A21 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONI.Pwith the same construction,you can
submit one form. 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 tfdifferent(example-3i 200'and 2@100) construction to the following:
10.Static water level below top of casing: 25 (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
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(gpm) 35 Method of test: Air 24a 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013