GW1-2021-05865_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY: Q
This form can be used for single to multiple wells `
I.Well Contractor Information: I
Dwight L. Huneycutt FROM
WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name JUL 34 ft 350 ft 1 gpm
4070-A ploGessln9 ft 417 ft. 1 gpm
NC Well Contractor Certification Number t `ryn,'J�1fl� c Q�Q(1 15.OUTER CASING for multi cased wells OR LINER if a livable
' FROM TO DIAMETER THICKNESS I%IATERIAI.
Derry's Well Drilling, Inc. 0 ft• 50 ft- 6 1/8 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-too
20-560 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. tr. in.
List all applicable well permits die.County,Slate,Variance,Injection,etc.)
ft. fL in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooting Supply) OResidential Water Supply(single) ft. ft. `a
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well-
[]Monitoring ❑Recovery
3 ft. 35 ft. Bentonite Pumped
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO DIATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
tr. tr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if oecessaryj
❑Geothetmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colon hardness.soNroek type.grain sae,etc
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 fit- 13 ft Brown Dirt
4/28/21 13 ft- 22 ft. Brown Rock
4.Date Wells}Completed: Well 1TI# 22 ft 465 rt• Slate
Sa.Well Location: ft. ft.
Pinnacle Homes USA LLC ft. FL
Facility/Owner Name Facility iD#(if applicable) ft. tt. Seams:'69', 114', 154', 167', 172',323',
4809 Stack Rd., Monroe 28112
ft. rt. 245'=1 g,412'=1 g
Physical Address,City.and Zip 21.RFMARKS
Union 04051009R
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one NtAong is sufficient)
N W 5/10/21
Signature ol'Certitied Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify,that the well(s)was(sere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑NO copy ofthis record has been provided to the well owner.
If this is a repair,f Ii out known well construction information and explain the nature of the
repair under ri21 remarks section or on the back ofthis 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.
h'or multiple injection or non-wafer supply wells ONLY with the same construction,you can
.suhmit one form SUBMITTAL TNSTUCTiONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdierenl(example-3@200*and tea 100') construction to the following:
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10.Static water level below top of casing: 47 (ft,) Division of water Resources,information Processing Unit,
If water icnel is above casing,use^+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iiection Wells ONLY: i'n addition to sending the form to the address in
Rotary 24a 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 2 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. If
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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