GW1--02720_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
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1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES . R
FROM TO DESCRIPTION
Well Contractor Name 112 ft 127 ft I 1 20gpm
2465-A ft. ft. . I I
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 93 ft 61/8 ;.° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
379958 FROM TO DIAMETER THICKNESS MATERIAL .
2.Well Construction Permit#: ft ft ;in.
List all applicable well permits(Le.County,Slate,Variance,Injection,etc.)
ft. ft 'in.
• 3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft f
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity 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)
❑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 11- 60 Brown Dirt
7/31/23 60 ft- 85 It Junky Rock
4.Date Well(s)Completed: Well ID#
85 ft- 145 ft 1 Blue Granite
5a.Well Location: n." ft.
Kayla Reiszel ft
Seams: 106', 112-127'=20g
-20g
Facility/Owner Name Facility ID#(if applicable) .
ft. ft. i'
1255 Makers Way, Salisbury 28146 ft. ft {
Physical Address,City,and Zip 21.REMARKS x :
:."'1-)
Rowan 608 024 (,,_
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County Parcel Identification No.(PIN) J I AQ r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Y , } ����
(dwell field,one lat/long is sufficient) eG i.r w •r,l ?`_^
N W J/ � �� f .: %• ;•/23
o- W. c Cd_,s,:3
Si lure of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that;the well(s)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: ❑Yes 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
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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 if different(example-3@ 00'and 21100) 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 Injection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this;font 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
13a.Yield(gpm) 20 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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