GW1-2021-05863_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY: ¢
This form can be used for single or multiple wells
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1.Well Contractor Information: I
Dwight L. Huneycutt ��� F4.WATER ZONES
� FROM TO DESCRIPTION
Well Contractor Name 445 " 450 k• 1 gpm
4070-A ,uL 9 ZO21 ft. k. I i
NC Well Contractor Certification Number V�It 15.OUTER CASING for multi-cased wells OR LINER if a licable
Derry's Well Drilling, Inc. tCt'�310 pl0�esOn 9 FROM k To ft DL�METER in THICKTESS MATERIAL
�{�`Pp 0 57 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
20-564 FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: ft. k. in.
List all applicaRe irell permits(i.e.County.State,Variance,Injection,etc.) ft. k. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM 1 '1'0 MATERIAL. EMPLACEMEN"1'MBI'll D&.AMOUNT
❑lrri ation 0 3 rt. Bent.Chips Gravity
Non-Water Supply Well:
[]Monitoring ❑Recovery
3 ft- 35 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.
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El Aquifer Test ❑Stormwater Drainage it. 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. rain siz etc.
❑Creothemtal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) 0 k. 24 ft. Brown Dirt
1/29/21 24 k 33 ft• Brown Rock
4.Date Well(s)Completed: Well IDq 33 ft• 45 ft• Junky Blue Rock
5a.Well Location:
45 ft. 825 ft. Slate
Pinnacle Homes USA LLC
ft. ft.
Facility/Owncr Name Facility ID4(if applicable) ft. ft.
Seams: 138', 190',276',313',387',
4801 Stack Rd., Monroe 28112
ft. ft. 445'=1g
Physical Address,City,and Zip
21.REMARKS
Union 04051009P
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one fat/long is sufficient)
N W Lt ,L. 5/10/21
Signature o Certified Well Contractor 41 Date
6.Ls(arc)the wcII(s): PIPermanent or ❑Temporary i, /) /
/h'signing[Irisj orni,/hereby certi that the a e!/,c u•as were constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consirnefion Smndards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy cf this record has been provided ft)the hell owner.
1f this is a repair,ill(Pitt known well construction information and explain the nature q f the _
repair under::11 remarks section or on the hack of 1his firni. 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.
Por nudliple it iection or non-rraier.supply ire/Ls ONLY u•ilh the same construction,you can
submit one ftrni. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 825 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hbr multiple irells list till depths ifdiferenl(example-3 a 00'and 2 a,100') construction to the following: j
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10.Static water level below top of casing: 75 (ft.) Division of Water Resources,Information Processing Unit,
lfirater 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
Rotary 24a above, also submit a copy of this,form within 30 days of completion of well
12.Well construction method: 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) 1 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 health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources l Revised August 2013
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