GW1--01920_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1 '
This form can be used for single or multiple wells
1.Well Contractor Information: '
Dwight L. Huneycutt 14.WMATERZONES DESCRIPTION
Well Contractor Name '--- .'',7::), f f 112 ft 115 ft I ' .8 gpm
4070-A 1.4 4.,, a 'Le 128 ft 133 ft I , 42 gpm
NC Well Contractor Certification Number /� ^ 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
MAR k 2 L• 2024 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 93 It 61/8 ! in' SDR-21 PVC
Company Name IIWG:fro-x>2al e ;-,-/-\-Amtv4ti Liv t 16.INNERCASING OR TUBING(geothermal closed-loop)
369733 DINCci'llOG FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. j in.
I
List all applicable well permits(Le.County,Slate,Variance,Injection,etc.)
ft ft. 1. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 11 SLOT SIZE THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Pdblic ft. ,
0 Geothermal(Heating/Cooling Supply) ElResidentiai Water Supply(single) ft it in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft ft
Non-Water Supply Well: 3 Bent.Chips Gravity
OMonitoring ❑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 j
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain use,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 18 ft. Red Clay
4.Date Well(s)Completed: 5/17/23 Well ID# 18 ft 44 ft Sandy Brown Dirt
44 ft 78 ft Junky Brown Granite
5a.Well Location: 78 ft 145 ft• Blue Granite
Seth Thompson ft.
Facility/Owner Name Facility 1D4(if applicable) '
265 Joe Lentz Rd., Salisbury 28146 ft. ft.
105', 109', 112'=8g,115',
ft ft 118', 128-133'=42g
Physical Address,City,and Zip 21.REMARKS
•
Rowan 510 056
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 t7GZx tL. 6/1/23
Signature of ertrfied Well Contractor Date
6.Is(are)the well(s): 127Permanent or OTemporary
By signing this form,I hereby cert fy that the wells)was(were)constructed in accordance
with ISA 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 EINo 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 fora. 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
1
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(Qa 100) 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,iRaleigh,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 Center,Raleigh,NC 27699-1636
50 Air 24c.For Water Supply&Infection 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 Ib, 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