GW1--02705_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY:rn
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight14.L. Huneycutt FROM TO
y FROM TO DESCRIPTION
Well Contractor Name 248 ft 255 ft I I 2 gpm
4070-A ft. ft. I l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 48 ft 61/8 In SDR-21 PVC
Company Name 16.INNER CASING OR TUBING.(geothermal closed-loop)
2023028W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) n ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. H. in.
DAgricultural ❑Municipal/Public
ID Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft rt. in
❑lndustrial/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:
OMonitoring ❑Recovery 3 ft- 20 ft Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
tt. ft.
:Aquifer Test ❑StormwaterDrainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft 13 ft ;, Red Dirt
4.Date Well(s)Completed: 12/29/23 Well ID!! 13 ft 29 ft Brown Dirt
' 29 ft 485 ft Slate
5a.Well Location: ft.
Jeff Pitman ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:56',63',79',95', 134', 178',221'
Tuckertown Rd, New London 28127
Physical Address,City,and Zip ft.
t 1:- t_ ,24$'=2g
21.REMARKS {: :t= ':,. : .r. li f.,�,:
Montgomery 6663-10-26-8238
County Parcel Identification No.(PIN) MAY ii 'j .e024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatiop
(if well field,one las/longissufficient) lfi'C:t 4.1.1`"i 17r,^!,1,44,ii-,3 Ui??
�Gti. D� JIB?r-7. 1/15/24
N W r/
Signature of drtified Well Contractor ' Date
6.Is(are)the well(s): 12IPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 421 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
S.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 INSTU CTIONS
9.Total well depth below land surface: 485 (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 2Q100' construction to the following:
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
1'
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY:'In addition to sending the form to the address in
Rotary24a above, also submit a copy of:this form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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
13a.Yield m 2 Method of test: Air 24c.For Water Supply&Injection Wells:
(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 Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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