GW1--07572_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
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1.Well Contractor Information:
Dwight L. Huneycutt 14.WryIATER ZONES DESCRIPTION
Well Contractor Name 83 ft 86 ft- 1 5 gpm
4070-A 95 ft 100 ft 5 gpm (130-140'=15gpm)
NC Well Contractor Certification Number `15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable)`
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 82 ft 61/8 i i►- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
393042 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
tt ft in.
❑Agricultural ❑Municipal/Public ,
• ❑Geothermal(Heating/Cooling Supply) g]Residential Water Supply(single) it ft. in.
„
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it 3 ft Bent.Chips Gravity
Non-Water Supply Well:
pMonitoring ❑Recovery 3 ft 20 ft Bentonite • Pumped
• Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test'' • DStormwater 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 type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 13 ft- Red Dirt
6/8/23 13 ft- 46 ft Dry Sandy Brown Dirt
4.Date Well(s)Completed: Well ID# 46 ft- fib ft- i. Wet Sandy Brown Dirt
5a.Well Location: 68 ft 145 f Blue/White Granite
South Ridge Properties, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:80',83'=5gpm,90',95'=5gpm,
3345 E. Ridge Rd., Salisbury 28144 ft ft. 130'=15gpm T.. '-,•• f-*
Physical Address,-City,and Zip 21.REMARKS 1 -r'ii lj(ram' I )
Rowan 322 043 `'.
County Parcel Identification No.(PiN) NOV 2 1 2)23
.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '22.Certification: I of;;' '~n;:1,-,---„,...- rr i'-'=
(if well field,one lat/long is sufficient) /'� r�":,.-. .� "'I
N W 6/28/23
Signature oftertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby cert that the well(s)was(were)constructed in accordance
with 15A 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 E1No 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#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
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9.Total well depth below land surface: 145 (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@I00' construction to the,following: I
10.Static water level below top of casing: 30 (ft) Division or Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter; 6 (in,) 24b.For Injection 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: ry 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 Ce ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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 -