GW1--05041_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DWI ht L. Hume`curt 14.WATER ZONES
g 7 FROM TO DESCRIPTION
Well Contractor Name 615 ft. 625 ft I 2 gpm
i... ' " .1
4070-A ri.n_._dw,I.:i Mir' D ft. ft.
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wells)OR-LINER(if ap licable)-
0 2023 FROM TO DIAMETER , THICKNESS MATERIAL
Derry's Well Drilling, Inc. AUGvu0 ft. 50 ft- 61/8 SDR-21 PVC
Company Name 1
p y.�.�.rI 1 fir^Y � UnX 16,INNER CASING OR TUBING(geothermal closed-loop)
22-30V FROM TO DIAMETER THICKNESS MATERIAL
•2.Well Construction Permit#: rDtiet 3OG ft fr. hi.
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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
•
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft
• 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft. 'Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery CI Salinity Barrier ft ' ft
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary --
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain sire.eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 1t Red Dirt
3/4/23 8 ft 29 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
29 ft. 800 ft Slate
5a.Well Location: ft. ft
Pinnacle Homes USA, LLC ft. , f
Seams:78',99', 145', 177',255',290',
Facility/Owner Name Facility ID#(if applicable)
4205 Old Pageland Marshville,Wingate 28174(Lanes Creek Acres,Lt2) fr 320',415',425',465',610',615'=2gpm,
ft. ft. 690',720',769'
Physical Address,City,and Zip
-21.REMARKS .
Union 03-099-009B
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 ,77f)� �""�}'—
Lyi/eazredt- 3/30/23
Signature of ettifred Well Contractor Date
6.Is(are)the well(s): l27Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fin out known well construction information and explain the nature of the
repair under fi21 remarks section or on the back of this 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 nmltip/e 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: 800 (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 214)100) construction to the following:
10.Static water level below top of casing: 75 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,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: ry 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 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.
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Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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