GW1-2022-04365_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:
Dwight L. Huneycutt 4 14.WATER ZONES
i
Y ?` (�j 7 FROM TO DESCRIPTION
Well Contractor Name 154 ft. 160 ft 8 gpm
4070-A APR 1 1 202? ft. fL
NC Well Contractor Certification Number 15.OUTER
CASING for mulDMed we,llsRNRE SiSf alcable
FROM TEROT MAT ERIAL
Q
Derry's Well Drilling, Inc. m'il ft. 77 ft 61/8 4- 1 SDR-21 PVC
q 16.INNER CASING OR TUBING eothermal closed-loop)
Company Name
359497 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL 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.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft IL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT -
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
3 ft' 35 fL BentOnite Pumped
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
FROM TO I MATERIAL 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 eecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soNrock type,giri.size,etc.)
El Geothermal(Heating/Coot ing Return) ❑Other(explain under#21 Remarks) 0 ft- 13 ft. Red Dirt
2/22/22 13 ft- 39 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
39 fL 58 ft. Wet Brown Dirt
5a.Well Location: 58 ft- 68 ft. Junky Rock
Drew Arey/Clayton Homes 68 ft. 225 ft. Blue Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft.
228 Buckshot Trail, Salisbury 28146 (Hunters Run Lt7) seams: 89',s6',99', 125', 132',
rL fL 154'=8gpm
Physical Address,City,and Zip 21 REMARKS
Rowan 606GO26
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 3/8/22
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 0No 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 P21 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
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 INSTUCTIONS
9.Total well depth below land surface: 225 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 26 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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. Rotary 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) 8 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013