GW1-2021-00820_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO I DESCRIPTION
Well Contractor Name 276 ft. 280 ft' 15 gpm
4070-A ft. fL
NC Well Contractor Certification Number IS.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER TH/CIINFSS MATERIAL
Derry's Well Drilling, Inc. 0 fL 83 ft- 61/8 'ia SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-180 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit$h ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipaUPublic fL ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 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 a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sou/mck type,grain s' etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 34 ft. Brown Dirt
9/24/21 34 fL 55 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
55 fL 300 fL Slate
58.Well Location: & &
Pinnacle Homes ft
Facility/Owner Name Facility to#(ifapplicable) ft
6205 Philadelphia Church Rd., Marshville 28103 (Lot2) Seams: 121', 150', 175',250',259',
ft. 276 '5gpm;'t-r-;C E�
Physical Address,City,and Zip 21.REMARKS ! `•
Union 03-111-009B 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
D r �N w 10/28/21
� � _
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): 10Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.IS this a repair to an existing well: ❑Yes or BNo copy ofthis record has been provided to the well owner
lfthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 26 (ft) Division of Water Resources,Information Processing Unit,
lfwater 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 15 Method of test: Air Also submit one copy of this forme 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. i
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013