GW1-2023-01610_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells Ikl
1.Well Contractor Information:
Dwight L. Huneycutt 14.FRO WATER ZONESM TO DESCRIPTION
Well Contractor Name _ 370 1" 380 ft. I I 1
4070-A "" +®t--y i� ? Vy rt fr 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased webs`•OR LINER if a litable
FEBn^� FROM TO DIAMETCR I i TmCIaVFSS MATERLII
Derry's Well Drilling, Inc. LC� hL 0 ft- 45 ft- 6 1/8 'n SDR-21 I PVC 1
Company Name Inivfn%Ri,i^1 f r'`C-1: '�1�I; t FROMNERCTSOINGORTIIB�TERhermalTM eC*Es.S MATERIAL
22-148 Jt+'c`QJ'9'.:��x
2.Well Construction Permit#: ft.
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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft ft in
ft ft.❑Geothermal(I3eating/Cooling Supply) Residential Water Supply(single) m
„
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT !
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01trigation 0 & 3 ft. Bent.Chlp's Gravity
Non-Water Supply Well:
3 It. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery •
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation, 19.SAND/GRAVEL PACK if a litable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL ' EMPLACEMENT METHOD
ft fr.
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRII710N cbtor,hardness soillrock 'n sae,etc.
[:]Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft- 6 ft. i' Brown Clay
4,Date Well(s)Completed: 10/28/22 Well ID# 6 14 & i Brown Dirt Rock
14 fL 600 ft Slate
5a.Well Location: ft. fL
Pinnacle Homes USA, LLC
ft. ft. Seams:54',59',68',95',112',174',
Facility/Owner Name Facility ID#(ifapplieable)
3220 Austin Chaney Rd., Monroe 28110(Morgan Acres U8) fr. fL 205',234',275',313',327',370'=1gpm
ft. sr.
Physical Address,City,and Zip 21.RENJARKS
Union 08-078-030 r
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) i;
N w j 11/12/22
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
BY signing this farm,I hereby cerlo that the„sve!!(s)was(were)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 EINo copy ofthis record has been provided to the well owner
lfthis is a repair,jilt out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 23fSite diagram or additional well detiiiis:
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
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i di eren!(example-3 00'and 1 100 construction to the Following:
P P j .1T ( P @2 @ � g: I,
72 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (it)
Ifsvaterlevel is above caring,use•'+" 1617 Mail Service Center!,laleigh,NC 27699-1617
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: j
(Le.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 276994636
1 13a.Yield Wm) Method of test: Air 24c.For Water Supply&Infection Wells j
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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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