GW1-2021-04512_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �� ' `` 178 ft• 185 ft ` 35 gpm
2465-A 2p21 ft. fL
NC Well Contractor Certification Number P`R 2 15.OUTER CASING for mulfi-cased wells OR LINER if a lice le
r Q Un FROM TO DIAMETER T=---- S MATERLALL
Derry's Well Drilling, Inc. prc��� 0 ft 58 s 1/8 j " SDR-21 PVC
Company Name %16 G 6\N1R " 16.INNER CASING OR TUBING(geothermal closed400
20-470 FROM TO DIAMETER TMCXNES3 I MATERIAL
2.Well Construction Permit#: ft. ft. ! in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
It. fL in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. m
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) % fL rn
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 % 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 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 TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,haAness,soitfrock typt,grain e' etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 38 ft Brown Dirt
1/6/21 38 fL 200 ft• Blue Rock
4.Date Wells)Completed: Well ID# & ft.
5a.Well Location: fL ft.
Pinnacle Homes USA ft. ft.
Facility/Owner Name Facility 1D#(if applicable)
5203 E Lawyers Rd., Wingate 28174 (Hell Acres Lt2) ft. fL Seams: 68', 125', 178'=35g
ft ft
Physical Address,City,and Zip 21.REMARKS
Union 02-199-069
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 (,{� Y 1/26/21
Sig#dtre of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)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 ElN0 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 921 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
S.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: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 14 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:1 In addition to sending the form to the address in
Rotary 24aabove, also submit a copy ofithis 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) 35 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form lwithin 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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