GW1-2023-01658_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells III
1.Well Contractor Information:
Dwight L. Huns cuff 14.WATERZONES l •i "
g Y FROM TO DESCRIPTION
Well Contractor Name ` �` r� 250 f- 255 B" 5 gpm
4070-A ._� ��a ;� ft. ft.
NC Well Contractor Certification Number FEB �/1�� 15.OUTER CASING for multi casetl,wells OR LINER if a licable
'v It FROM TO DIAMETER THICIQHESS MATERIAL
Derry's Well Drilling, Inc. o ft. 79 ft 6 1/8 ;; '- 1 SDR-21 PVC
Company Name �tr5r .��_„ ' .7 Unif 16.INNER CASING OR TUBING eothermal dosed-loop)
357504 IA
/�y�7 FROM TO DIAMETER THICKNESS " MATERIAL
2.Well Construction Permit#: ft. ft. is
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
❑Agricultural ❑Municipal/Public ft ft in i
❑Geothermal(Heating/Cooling Supply) f iResidential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fl, 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 fr Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDlGRAVEL PACK if applicable)
FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer 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)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPMON color,hardness,soil/rock- a 'n size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft Fill Dirt
4.Date Well(s)Completed:, 7/1/22 Well ID# 11 ft- 44 ft Brown Dirt
44 fL 62 ft. " Brown Rock
5a.Well Location:
Wesley M 62 fr. 305 fc Slate
Y Myers ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
Harper Hearne Rd, New London f` ft- Seams:82',86',98', 109',113', 121', 130',
ft ft. 139', 195',250'=5gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 36309
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifw sufficient)ell field,one lat/long is scient)
N W DGU27""� J , 7/19/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this fornx 1 hereby certify that the uvll(s)spas(wore)cowhwr rod in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 iVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided tothe}veil owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarls 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: 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: 305 (ft) 24a. For All Wells: Submit thisi form within 30 days of completion of well
For multiple wells list all depths ifdtjferent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
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11.Borehole diameter. 6 (in.) 24b.For Injection Wells ONLY: IIn,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 Ccater,Raleigh,NC 276994636
13a.Yield(gpm)
5 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disiufectiontype: Granular Amount, 1/2 lb• well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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