GW1-2021-05870_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
I.Well Contractor information:
Dwight L. Huneycutt F4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4070-A REG �� ft. ft.
NC Well Contractor Certification Number 0 �Orl 15.OUTER CASING for multi-cased wells OR P.iNER if a licable
L FROM TO DIAMETER THICleo-% MATERIAL
Derry's Well Drilling, Inc. JUG ft' 52 ft- 6 1/8 SDR-21 PVC
Company Name ry ♦ �SrJOeS5 16.INNER CASING OR TUBING(geothermal closed-loop)
20-561 „I�;a1ta11 rt;On FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �0�� ��N-A se., ft. ft. 1n
List all applicable well permits ri.e.County,State,VarianCe,Injection,etc.)
ft. I 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(Heatmg/Cooling Supply) BResidential Water Supply(single) ft. ft, im
❑industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation p & 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 35 ft- Bentonite Pumped
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I9.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardnms,soil/mck type,grain size,de.
❑Geothermal Heating/CoolingReturn ❑Other(explain under#21 Remarks) 0 ft- 12 ft Brown Dirt
12 ft, 22 ft. Brown Rock
4.Date Well(s)Completed: 4/29/21 Well iD# � 22 ft- 900 ft- Slate
Sa.Well Location: ft. ft.
Pinnacle Homes USA LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:74', 137', 176',211',413',630',
4813 Stack Rd., Monroe 28112
rt. rt. 639'
Physical Address,City,and Zip 21.REMARKS
Union 04051009S Well is very low yield,but does produce some water,however
County Parcel identification No.(PiN) not sustainable for a household.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field.one lat/long is sufficient)
N W rGt�LP��'�Gl�` 5/15/21
Signature of Certified Well Contractor V Date
6.IS(are)the well(s): 101'ermanent or ❑Temporary Ry signing this form,I hereby certify that the well(s)was 6vere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,f/l out known well construction information and explain the nature of the
repair under;ill 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.
toy multiple injection or non-water supply wells ONLY with the same construction,you can
.submit ane form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 900 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
Ear multiple wells list all depths ifdifferem(example-3@200'and Ica 100') construction to the following:
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10.Static water level below top of casing: 147 (ft.) Division of Water Resources,information Processing Unit,
If}rater level 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
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.anger,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) N/A 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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