GW1-2021-04521_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: h `
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 318 ft' 322 ft' j 1 gpm
4070-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR 2 9 2021 0 ft 60 ft 61/8 'n• 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
Cessing Und. FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 20-5��xwlt,3it013 Pro ft• rt• !n•
List all applicable well permits(i.e.County,St�rVarianct"4 P9i-.J+
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well•' FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
k. ft.
ft. ft. n
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
3 rc. 35 ft• Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable.)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
tt. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets itnetRssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tcolor,hardness,soi0roek type,grain sim etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 28 ft. Brown Dirt
1/29/21 28 it' 575 ft• Blue Rock
4.Date Well(s)Completed: Well ID# ft R
5a.Well Location:
Pinnacle Homes USA LLC ft. ft.
Facility/Owner Name Facility ID4(if applicable) ft. ft' SearnS:71',96', 123', 155',208',240',
4805 Stack Rd, Monroe 28112 (Lt 13)
rt. rc. 277', 318'=1g,471'
Physical Address,City,and Zip 21.REMARKS
Union 04051009Q
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 2/15121
Signature of Certified Well Contractor C; - Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the,cell(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy of this record has been provided to the null onwer.
If this is a repair,fill out known ivell construction,information and explain the nature of the
repair under 921 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.
For multiple injection or non-mater supply wells ONLY uith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 575 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ne/ls list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 64 Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
1I.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: If
(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
i
13a.Yield(gpm) 1 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form iwithin 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health epartment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013