GW1-2021-05871_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY: k This form can be used for single or multiple wells
1.Well Contractor Tuformation: �� �
John W. Huneycutt 14.WATER ZONES
Y FROM I TO I DESCRIPTION
Well Contractor Name L O 9 235 fL 240 ff 1.5 gpm
2465-A �u ft. ft.
r'] @&5�n9 nil
NC Well Contractor Certification Number d�D 1-Cow 15.OUTER CASING for multi-cased wells OR LINER if a licable
'(j�OIIM'D�n1:�se-e%On FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. .Y 0 ft 46 ft 6 1/8 in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
21-189 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(11.e.County,State,Variance,Injection,etc.)
ft, ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLATSIZE THICKNESS MATERIAL
ft. ft. im
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) fr. ft
❑industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑itri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 35 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK if applicable)
❑ FROM TO Aquifer Storage and Recovery ❑Salinity Barrier ft. R. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
tr. tr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soilimck lyiie,grain size,etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 19 ft. Red Dirt
4.Date Well(s)Completed: 6/1/21 Well iD# 19 iL 440 ft- Slate
fc ft.
5a.Well Location: ft ft.
Pinnacle Homes USA LLC rt. ft-
Facility/Owner Name Facility 1D4(if applicable)
4813 Stack Rd., Monroe 28110 rL rL Seams:59', 165',235'=1.5g,348',394'
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 04051009S
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degreeshWnutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Iat/long is sufficient) (/�/,�/ /' /
N w �"�G�L W. �GaZ¢�f"`t.'L' 6/15/21
Si lure of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By.signing this form,1 hereby certify that the well(v)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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 r'21 remarks section or on the back ofihis 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.
tar multiple injection or non-water supply wells ONLY with the.same construction,you can
submit one form. SUBMTTTAL TNSTUMONS
9.Total well depth below land surface: 440 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
for multiple wells list all depths ifd8erent(example-3@200'and 1@100') construction to the following:
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10.Static water level below top of casing: 45 (ft,) Division of Water Resources,information Processing Unit,
Ifwater level is abme casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 24b.For injection 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:
(ix.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection,Wells:
13a.Yield(gpm) 1.5 Method of test: Air Also submit one copy of this forth 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. t
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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