GW1-2023-02685_Well Construction - GW1_20230411

I '
I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 101 ft. .
110 ft I 1 gpm
ti , —
2465-A ZQ 23 454 ft. 460 ft- I 2 gpm
APR 1 ji
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ; ;�.;-.,:, ;, : r< :,•-:; 3 1Sfi,i 0 fL 53 ft- 61/8 - in I SDR-21 I PVC
Company Name v'J'v U"'-5 t a L 16.INNER CASING OR TUBING 6motbermal closed-loon)
365818 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits fl.e.County,State,Variance,Injection,etc.)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft ft. is
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 fL Bentonite Pumped
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. It.TO nATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DFSCREMON(color,hardness,sell/rack type,gTain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Red Dirt
1/28/23 5 ft. 25 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
25 ft. 465 ft• Blue Rock
5a.Well Location: ft. ft.
Pinnacle Homes USA LLC
Facility/Owner Name FacilityIDH(ifapplicable) ft. ft Seams:57',69',85', 101-110'=19pm, 190',
ft. ft: 197',235',310',454'=29pm
Ridgecrest Rd,Locust 28097 (Lot 4) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 447
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:ffi 1 �(/
rG1Ti W Y l
N w 2/14/23
Sign of Certified Well Contractor V Date
6.IS(are)the well(s): 01ermanent 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 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 421 remarks section or on the back ofthis farm. 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 INSTUCTIONS
9.Total well depth below land surface: 465 (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 casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel 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:
(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 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24a 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 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
I