GW1-2023-01535_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES
Y FROM TO DESCRIPTION
Well Contractor Name 150 ft 160 ft- 35 gpm
4070-A ft. ft.
NC Well Contractor Certification Number • &.,_ ,-,„ v..'' for l5.OUTER CASING( multi-cased wefts)OR LINER(if ap liable)
>4 L„ 4 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 66 ft 61/8 SDR-21 PVC
FEB 1 2023 Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
240763 FROM TO _ DIAMETER , THICKNESS MATERIAL
2.Well Construction Permit it: t 1t ft. in.
List all applicable well permits(i.e.County,State,Variabe;Actecninrle-N' f::':.4.i13(.rtii
J.,Q! 0(,—; ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
n ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 3 tQ Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 20 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft,
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION I color,hardness,.will rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Brown Dirt
4.Date Well(s)Completed: 8/9/22 Well ID# 15 f< 56 ft Boulders
56 ft 200 ft• Blue Granite
5a.Well Location: ft ft.
Elizabeth Belik ft. ft.
Facility/Owner Name Facility IDS(if appl tcable) ft. ' ft. Seams:70-77',85',92',95, 102-106',
1201 Riverwood Dr., Salisbury 28146 rt. ft. 109', 127', 134', 150'=35gpm
Physical Address,City,and Zip 21.REMARKS
Rowan 510B061
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
DeUL. 8/31/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2 Permanent or OTemporary By signing this fonts,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA 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 ElNo 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 e21 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
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: 200 (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3Q200'and 2@100) construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 28 (fL)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
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:
(ie.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) 35 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