GW1--01932_Well Construction - GW1_20240325

i '
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 'a
9 y FROM TO DESCRIPTION
Well Contractor Name 430 ft 440 ft ! ' 12 gpm
4070-A ft /ft f
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Beattie)
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 48 ft 6 1/8 a SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022019W FROM TO DIAMETER' . THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in..
List all applicable well permits(Le.County,State,Variance,Injection,etc.)
ft ft. i0.1
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM , TO DIAMETER ISLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public \ in.
I,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer 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)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 14 ft Red Dirt
4.Date Well(s)Completed: 6/15/23 Well m# 14 ft 29 ft Brown Dirt
29 ft 38 ft- , Brown Rock
5a.Well Location: 38 ft 500 ft Slate
Graham&Kimberly Shirley ft. ft ,
Seams:51',56',69',75',88',99',110', 118'
Facility/Owner Name Facility ID#(if applicable)
586 Pearl Bay Dr.,New London 28127(Heron Bay,Ph3,Lt44) ft. ft 179',309'',334',337',409',414',430'=12g
a, rt.
Physical Address,City,and Zip 21.REMARKS
Montgomery 6662-07-77-4812 _,, ,,� ,r,'r
County Parcel Identification No.(PIN) - " •-•ma's
MAfl 2 %.. 0
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i 224
(dwell field,one lat/long is sufficient) /
.c..-. Gu2�-r.I to /'Pr:jS/23'4:1 t!
N W G4f ,� rAtif,:2,t { n r�-
Signature o Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary
By signing this form,I hereby cer[ify that,the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1 lN0 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 I
repair under#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 with the same construction,you can
submit one fora SUBMITTAL INSTUCTIONS !'
9.Total well depth below land surface: 500 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@/00' construction to the following:
'1 1
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b-For Iniection 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: ,
(Le.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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 12 Method of test: Air 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
1