GW1--02735_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD For Internal Use ONLY: ,
This form can be used for single or multiple wells ,
1.Well Contractor Information:
Dwight L. Huneycutt FWATERZONES s
g y FROM , TO DESCRIPTION
Well Contractor Name _ 158 ft• 165 ft• j ' 5 gpm
4070-A r'i ( i f$,s -' 172 ft• 175 ft. 1 gpm
k -� i 1y p-" j 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number MAY A) 7 ^G�4 FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. c o ft. 145 ft• 6 1/8 ' •1O• SDR-21 PVC
Company Name to r i•'i's'41 ),-,:c•t rN;,„�td 16.INNER CASING OR TUBING(geothermal closed-loop)
22-372 1Z,� C.q.c.OG FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ! in.
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.
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) (]Residential 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:
OMonitoring ❑Rewvery 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 ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 23 ft. Red Clay
1/24/24 23 ft• 67 it Brown Dirt
4.Date Well(s)Completed: Well ID#
67 ft• 135 ft• Brown Rock
5a.Well Location: 135 ft• 300 ft' Slate
Pinnacle Homes USA, LLC •
ft. ft. , ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Seams: 158-165'=5g, 172'=1g,201-206'
3923 Vann Sneed Rd., Marshville 28103 (Lot 7) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 03-111-025G
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 PGti� L. � lt- 2/11/24
Signature of rtified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I 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.Is this a repair to an existing well: ❑Yes or ElNo 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 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 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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifderent(example-3@200'and 2@100') construction to the following:
1
10.Static water level below top of casing: 30 (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 Injection 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 '
(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
6 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this farm 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 ReLources Revised August 2013