GW1--05161_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:
L. Huneycutt 14.WATER ZONES
Dwight
Y FROM TO DESCRIPTION
Well Contractor Name 551 ft. 555 ft. 1 gpm
4070-A 586 ff. 595 f• 4 gpm
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 54 ft- 61/8 1°• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2024009W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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.
DAgricultural ❑Municipal/Pubiic
❑Geothermal(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 ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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,soilrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i 0 ft. 14 ft. Red Dirt
4.Date Well(s)Completed: 7/16/24 Well ID# 14 it Brown Dirt 29 f•
29 ft- 35 ft. Brown Rock
5a.Well Location:
Dave Beach 35 ft- 625 ft- Slate
ft. ft- Seams: 59', 71',77',84',96', 109', 158',215'
Facility/Owner Name Facility ID#(if applicable) ft. f.t
181 Kingfisher Cr., New London 28127(Heron Bay, Ph10, Lt22) 278P, 303, 314P,478P,494, 516P,533,
rt. ft. 551'=1g,579',586'=4g
Physical Address,City,and Zip 21.REMARKS
r- -
Montgomery 6662-05-29-2868
County Parcel Identification No.(PIN) • -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 4tj t1 'k 0 EHZ4
(if well field,one lat/long is sufficient)
7� / J:.:
N W v L�(fQ�.L--� !,�' I.�i.J_i.��5/24t� '
Signature of ertified 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 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 tt21 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: 625 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100) construction to the following:
Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: 40 (ft.)
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
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
24c.For Water Supply&injection Wells:
13a.Yield(gpm) 5 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