GW1-2023-02714_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 109 ft. 115 ft. 759pm
4070-A ft. ft
4 15.OUTER CASING for muiti-cased wells OR LINER if a livable
NC Well Contractor Certification Number i y „; p
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. -, ,, � 0 ft 71 ft- 61/8 SDR-21 PVC
Company Name APR is 16.INNER CASING OR TUBING(geothermal closed-loop)
329274 - FROM TO DIAMETER ' THICKNESS MATERIAL
2.We11ConstructionPermit#: -- -^��^n %'1 -'`:'.'I 1;t;:z ft ft. in.
List all applicable ivell permits(l.e.County,State,Variance,
fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) lOResidential Water Supply(single) it ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC K if applicable)
FROM TO MATERIAL EMPLACFAUEN MIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
❑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/rock tyM grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft. 7 fr. Brown Dirt&Boulders
4.Date Well(s)Completed: 1/19/23 Well ID# 7 ft 45 ft. Sandy Brown Dirt
45 ft. 55 ft. Brown Granite
5a.Well Location: 55 ft. 125 ft. Gray&White Granite
Jocelyn Ferguson ft. ft
Facility/Owner Name Facility ID#(if applicable)
163 Wood Lake Dr., Salisbury28147 ft ft Seams:7T, 109'=7agpm
fr. fr.
Physical Address,City,and Zip 21.REMARKS
Rowan 306DO08
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifweU field,one]at/long is sufficient)
N W ��� Gu2P-u 2/10/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 1 5A 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 EINo copy of this record has been provided to the ire//owner.
If 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 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 hoction or non-water supply rvells ONLY with the same cons itedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple rvells list all depths ifdierent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994613
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;foam within 30 days of completion of well
17.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 276994_636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 75 Method of test: Air Also submit one copy of this form w.ithin 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county heatthl department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013