GW1--05159_Well Construction - GW1_20240830

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 79 ft 83 ft 1.5gpm
4070-A 571 ft 575 ft 1.5gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap able)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 62 k 6 1/8 at SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023031W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
B. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
EL H. in.
❑Agricultural DMunicipaVPublic
0 Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.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 ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier -
❑Aquifer Test ❑Stormwater Drainage
ft ft.
0 Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,pain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 44 ft Brown Dirt
4/12/24 44 ft 52 ft Brown Rock
4.Date Well(s)Completed: Well ID#
52 ft 600 ft Slate
5a.Well Location: ft.
Eugene Gotbaum ft. f't
Seams:68',72',75',79'=1.5g, 155',390'
Facility/Owner Name Facility ID#(if applicable) R
137 Channel Ct.,New London 28127(Heron Bay,Sec9,Lt155) 414', 571'=1.5g
Physical Address,City,and Zip 21.REMARKS ( • a - �h
Montgomery 6662-07-58-0717 •
County Parcel Identification No.(PIN) A U G d
0 1GZ4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification <-
If,:v::.n.:. arc,;:-,,u+,
(if well field,one lat/long is sufficient)
�C^Gh � L`., •2 j a .�7"".�p.
N W
8/2124
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 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 1No 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 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: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 200'and 2@/00') construction to the following:
10.Static water level below top ofcasing: 30
(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 Iniection 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
3 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
I3b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013