GW1-2023-02649_Well Construction - GW1_20230411

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 75 ft 85 ft 4gpm
4070-A 222 ft 228 ft-
NC 3 9Pm
Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if n Guable
' APR 7 j ���� FROM TO DNMETER . THICKNESS MATERIAL
Derry's Well Drilling, Inc. f� 1 0 ft' 67 ft.
6 1/8 SDR-21 I PVC
Company Name
:,;:i,.,;._ , 16.INNER CASING OR TUBING(geothermal closed-loop)
,,
22365 `-';,.. =�..":�,:::^:`/ ."1,.1 FROM To DIAMETER THICKNESS MATERIAL
-
2.Well Construction Permit#: ft ft. in.
List all applicable well permis(i.e.County,State,Variance,11 jection,etc.)
ft. ft. in•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS NUTERIAI,
ft ft. in-
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft as
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 D, 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 It- Bentonite Pumped
[]Monitoring ❑Recovery
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 % ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additions[sheets if necessa
❑Geothermal(Closed Loop) []Tracer FROM To DESCRIPTION color,hardness,soiUmck type.grain shr,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 % Red Clay
1/31/23 4 It 27 ft Brown Dirt
4:Date Well(s)Completed: Well ID#
27 ft• 39 ft Brown Rock
5a.Well Location: 39 ft' 47 ft. Junky Rock
Pinnacle Homes USA, LLC 47 ft- 320 f- Slate
Facility/Owner Name Facility ID#(if applicable)
ft. ft' Seams:6
4213 Old Pageland Marshville Rd,Wingate 28174(Lanes Crk Acres Lt4) Mpm, 147', 154', 172',
rt. ft. 198',222'-228'=3gpm .
Physical Address,City,and Zip 21.REMARKS
Union 03-099-009D
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) /
N `,ir D� 2/28/23
Signature of CQftfflcd Well Contractor Date
6.15(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that lite well(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 0No copy of this record has been provided to the well owner.
If this is a repair,ft11 out known rve11 construction inform aria n 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 320 (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 2@100) construction to the following:
10.Static water level below top of using: 38 (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,are"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection Well 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) 7 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 Ib. well construction to the county healthl department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013