GW1-2021-04513_Well Construction - GW1_20210429

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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:
John W. Huneycutt F4.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name �+�� •� 90 ft. 100 ft 4 gpm
2465-A � �02{ ft• ft.
NC Well Contractor Certification Number n 2 ` 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
p 1� vrii1 FROM TO DIAMETER TffiCKNESS MATERW.
Derry's Well Drilling, Inc. �;�s�n9 0 ft- 48 ft- 61/8 i° SDR-21 PVC
Company Name �OtCI',3�` sg� 16.INNER CASING OR TUBING(geothermal dosed400
20-471 p�,NR FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft fL 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 I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/CoolingSupply) OResidential Water SuPP1Y(single) ft. ft. in.
❑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 eentonite Pumped
Injection Well: ft' ft'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
❑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 mail/rack type,gmin s' eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 8 ft Brown Dirt
4.Date Well(s)Completed: 1/11/21 Well ID# 8 ft' 305 ft Slate
ft. ft.
5a.Well Location: ft. ft.
Pinnacle Homes USA
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams: 74%90'=4g, 154%215',248'
5205 E Lawyers Rd., Wingate 28174 (Heli Acres Lt1) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 02-199-070
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 1/26/21
Sign of Certified Well Contractor Date
6.Is(are)the well(s): i2]Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis 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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Infection 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: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources I Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 1 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