GW1--07570_Well Construction - GW1_20231121

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.WATER ZONES C
FROM TO DESCRIPTION
Well Contractor Name 75 ft 80 ft- I ; 3 gpm
. 4070-A 178 ft- 182 ft 1 ; 1 gpm
NC Well Contractor Certification Number 15.,OUTER CASING(for multi-cased Wells)OR LINER(if ap licable) .
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 25 ft- 61/8 1,is SDR-21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
374514 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. '. in.
List all applicable well permits(t.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
ft. ft in.
°Agricultural ❑Municipal/Public
ft❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM TO• MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. . ft.
❑Aquifer Test ❑Stormwater Drainage
. ft. ft. i.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 fc Brown Dirt
4.Date Well(s)Completed: 5/10/23 Well ID# 6ft. 9 ft Brown Rock
• 9 ft. 345 ft. . . Blue Granite
5a.Well Location: ft. • ft.
John &Kelli Isenhour ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:39',54',75'=3gpm, 118',
Ribelin Rd, Salisbury 28146 ft ft 156', 178'n1gpm _ _ _ __
Physical Address,City,and Zip 21.REMARKS ,G. '• .. -+-.u'+i t rr
Rowan 508 018 .. "—%.,, —;1 Ad q-..
County Parcel Identification No.(PIN) N O V {I j 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Y�
(if well field,one 1st/long is suflicient) Ins;.;,, „i-7n P_-^,; .:v,;-
Signature of Certified Well Contractor . Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this farm,I hereby cert(,j'that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes 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 i
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: 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: 345 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2QI00) construction to the following:
1
10.Static water level below top of casing: 30 (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 Infection Wells ONLY:I In addition to sending the form to the address in
Rota 24a above, also submit a copy ofithis form within 30 days of completion of well
12-Well construction method: ry construction to the following: '
(Le.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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 4 Method of test: Air 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013