GW1-2021-00821_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 139 ft• 145 ft' 2 gpm
4070-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi caned wells OR LINER if a ►icable
FROM TO DIAMETER' THICIQVEBS MATERIAL
Derry's Well Drilling, Inc. 0 66 fL 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-181 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) IL IL
❑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:
3 ft' 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK if a licable
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier IL It.
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness sod/mck type,grzin si etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Re]marks) ft- 25 ft. Dry Red Dirt
4.Date Well(s)Completed: 9/21/21 Well ID# 25 ft. 52 ft. Brown Rock
52 ` 425 ft. Blue Rock
58.Well Location: It. ft
Pinnacle Homes n. ft.
Facility/Owner Name Facility ID#(if applicable)6209 Philadelphia Church Rd., Marshville 28103 (Lot3) ft ft. Sea ms:96', i05 13'0;;139'=2gprri
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 03-111-009C
County Parcel Identification No.(PIN)
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,
N pwe � 10/28/21
Signature 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 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 425 (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 1@100') construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Iniection 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this fortri within 30 days of completion of
Granular 1 well construction to the county health department of the county where
13b.Disinfection type: Amount: �2 Ib.
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013