GW1-2021-05864_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD i
or in[emal Use ONLY: l
This form can be used for single or multiple wells pd�.
I.Well Contractor information:
Dwight L. Huneycutt tl II U 4.WATER ZONES
9 ZO`� FROM TO DESCRIPTION
Well Contractor Name ft• 325 ft. 4 1 gpm
4070-A in101M.3tlon Processn s6 ft• 372 ft• 1 gpm
NC Well Contractor Certification Number '1 [� R$eCf0 15.OUTER CASING for mu1H-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 61 ft- 6 1/8 SDR-21 PVC
Company Name 16.1NNER CASING OR TUBING eothermal dosed-loop)
20-562 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tr. tr. in.
all applicable well permits ri.e.County,State,Mariance,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. is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri anon 0 fL 3 ft. 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr. TO ft. MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. f[.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soiltr"A type..grain size,etc
❑Geothermal(Heating/Cooling Return) ❑other(explain under 421 Remarks) 0 ft. 12 ft. ! Red Clay
4/27/21 12 ft. 25 ft. Brown Dirt
4.Date Well(s)Completed: Well ill# 25 fG 42 ft. Brown Rock
5a.Well Location: 42 "' 425 ft' Slate
Pinnacle Homes USA LLC fL tL
Facility/Owner Name Facility iD#(if applicable)
ft. fL Seams'72',76', 168', 175% 182%320'=1g,
4721 Stack Rd., Monroe 28112 ft. fL 366'=1g
Physical Address,City;and Zip 21.REMARKS
Union 04051009N
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 W D� .c_ 5/10/21
Signature of-Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form.1 hereby certify that the well(s)was(mere)constructed in accordance
with 1 SA 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 R3No copy cfthis 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 112l 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.
Nor multiple injection or non-water supply wells ONLY with the.came construction,you can
submit one form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 425 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths efdifferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of easing: 49 (ft.) Division of Water Resources,information Processing Unit,
Ifivater level is above caring use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For injection Wells ONLY: I addition to sending the form to the address in
Rotary 24aabove, also submit a copy of tliis 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
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13a.Yield(gpm) 2 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 lb. well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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