GW1--07571_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
WJohn W. Huneycutt F4.FR MATER ZONES'TO DESCRIPTION
Well Contractor Name 95 ft- 100 ft- I ; 12gpm
2465-A ft: ft. I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o it• 84 ft- 61/8 'in- SDR-21 PVC '
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
376534 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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 MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public .
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. it in.
❑)ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 e. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 it' 20 ft: Bentonite , Pumped
Injection Well: ft. ft.
DAquifer 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.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) _
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain s'rre,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 60 ft- Brown Dirt
8/2/23 60 ft 75 ft- Brown Rock
4.Date Well(s)Completed: Well TM/
75 ft- 165 ft- Granite
5a.Well Location: ft ft.
John Fabian Reiszel ft: ft.
,
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:90',95-100'=12 gpm
Walton Rd (1220 Makers Way) Salisbury 28146 ft. ft.
Physical Address,City,and Zip 21.REMARKS ,' 9 ~-w'.__:.1 '*—,,_
Rowan 608063 " `` ��7s G9°:7
w,Nx:LL
County Parcel Identification No.(PIN) )' NU V j /1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: In;.-,.-r•-•<s, 2 202�
(if well field,one lat/long is sufficient)
did/ills i
ti D 1, "
N W
Si of Certified Well Contractor Date
6.Is(are)the well(s): l21Permanent or ❑Temporary By signing this form,1 hereby cern&thai'the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
If this is a repair,Jill 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
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: 165 (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 2@100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"+" 1617 Mail Service Center,
ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rotary24a 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
12 • Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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