GW1-2022-04368_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt -�,- i; { j 14.WATER ZONES
.i v FROM TO DESCRIPTION
Well Contractor Name 150 fL 155 ft• 30 gpm
2465-A 1'.u R 11 202? fL fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling Inc. 112 fL 6 1/8 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
335121 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n. fr. 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 ItIATERIAL
fL ft. in.
❑Agricultural ❑MunicipaliPublic
❑Geothermal(Heating/Cooling Supply) VIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 It. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
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 mcessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,wil/roek type,grainsim,ettc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 26 ft Brown Dirt
10/23/21 26 fl. 74 fL Brown Rock
4..Date Well(s)Completed: Well ID# 74 fL 90 ft. Unconsolidated Rock
5a.Well Location: 90 fL 165 fL Blue Rock
Astrid Vann ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams: 115', 130', 145', 150'=30g
350 Poole Rd, Salisbury 28146 ft. n.
Physical Address,City,and Gip 21.REMARKS
Rowan 626 117
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)N W
`pyL 66) � u� 11/15/21
Signa 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 [KIND copy ofthis 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 921 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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij)ereni(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifuvater 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
13a,Yield(gpm) 30 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: 112 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