GW1-2022-04364_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
t FROM TO I DESCRIPTION
Well Contractor Name s 170 ft 177 ft• 20 gpm
4070-A A 1 2022 ft &
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a hcable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's �'`-'` �` ' o ft.
rYs Well Drilling, Inc. 56 ft 6 1/8 SDR-21 PVC
,,,,,�zr;r;� it
Company Name t 16.INNER CASING OR TUBING(geothermal closed-loop)
359496 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
fL ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in
❑lndustriallCommercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 e. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr TO. ft MATERIAL: I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 16 ft. Red Clay
10/18/21 16 ft 38 ft Wet Brown Clay
4.Date Well(s)Completed: Well ID# 38 ft- 49 ft. Junky Brown Granite
5a.Well Location: 49 ft. 185 ft Blue Granite
Drew Arey/Clayton Homes ft. ft
Facility/Owner Name Facility ID#(if applicable) ft N• Seams'. 62-70',79',92%98', 170'=20gpm
250 Buckshot Trail, Salisbury 28146 ft. ft
Physical Address,City,and Zip 21.REMARKS
Rowan 606GO25
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) /
N W 11/5/21
Signature of Certified 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 BNo copy ofthis record has been provided to the well owner.
1f 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 ofthis 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: 185 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferem(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 24aabove, 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
13a.Yield(gpm) 20 Method of test: Air 24c.For Water Supply&Injection Wells:
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.
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Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013