GW1--02695_Well Construction - GW1_20240507

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 1FROM WATER•ZONES TO I
DESCRIPTION
Well Contractor Name 61 ft 65 ft. 2I gpm ' (75-84'=8 gpm)
4070-A 94 ft. 101 ft. I ! 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap.livable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 44 ft 6 1/8 1O� SDR-21 PVC ,
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
2022024W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft hi.
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
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft 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:
❑Monitoring ❑Recovery 3 ft 20 ft' Bentonite Pumped
Injection Well: ft ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑A uifer Storage and Recovery ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD
q g Salinity ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/roektype.groin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) , 0 ft- 26 ft. Brown Dirt
4.Date Well(s)Completed: 7/5/23 Well Mil
26 ft 32 ft. Brown Rock
32 ft. 265 ft. i Slate
5a.Well Location: ft. ft.
Holli Weber
ft ft Seams:49',54',61'=2g,75-84'=8g,
Facility/Owner Name Facility 11Nt(if applicable)
ft ft. 94-101'=2g
181 Heron Bay Rd, New London 28127 ft A
Physical Address City,and Zip -21.REMARKS
Montgomery 6662-08-99-6289 MAY ,`i COZ4-
County Parcel identification No.(PiN)
•
t'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: if/'JsFP,s4'ti 1 t I;,,..'''' J „
(if well field,one lat/long is sufficient) rich(:a L,'O,J
N W Z ,11t L 7/20/23
Signature a ertificd Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby cert 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.Ts this a repair to an existing well: ❑Yes or BNo 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=21 remarks section or on the back of this farm. 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 ONLPwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd/Jerent(example-3 ,200'and 2(100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
limier level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
i
II.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: lir addition to sending the form to the address in
Rotary 24a above, also submit a copy of i'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
12 Method of test: Air 24a For Water Supply&Injection Wells:
13a,Yield(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 Deparunent of Environment and Natural Resources—Division of Water Resources Revised August 2013