GW1-2022-10038_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES'
FROM I TO DESCRIPTION I I
Well Contractor Name t-11 g S IV y 270 ft' 276 f` I I 1 gpm
`/ j� ft. ft.
40NC Well o tractor Certification Number NOV V 7 2022 1&OUTER CASING for multi-cased wells O I'LI R if a licable
FROM TO DIAMETER �THICKNFSS MATERIAL
Derry's Well Drilling, Inc. r k'��Prac�.e-Ang Una 0 fl• 56 to 6 1/8 iti 1 SDR-21 PVC
ry g, Irlcvii(1>�+^�
Company Name Ly%n,t v zy5 16.INNER CASING OR TUBING eotherma[closed-loop),
21=106 FROM TO DIAMETER 'THICKNESS MATERIAL
2.Well Construction Permit#: 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 MATERLAL
ft. fr. in. ,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 23Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT .
FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. Bent.Chips' Gravity
Non-Water Supply Well:
3 ft. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I To I DESCRIPTION color,hardness,soillmek type,prain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. Brown Clay
6/11/22 6 ft- 21 ft. Brown Dirt
4.Date Well(s)Completed: Well EN
21 ft- 30 ft. Wet Brown Dirt
5a.Well Location: 30 tt. 525 it" Slate
Pinnacle Homes USA, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
5116 Tom Starnes Rd, Seams: 60',75',89', 110',270'=1gpm
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 05-020-004
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lattlong is sufficient)
N W / ' .N 7/7/22
Signature of ertified Well Contractor j Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis 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#21 remarks section or on the back ofthis form. 23.Site diagram or additional well It
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 saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 525 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@ 100� construction to the following:
10.Static water level below top of casing:
65 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 1 Method of test: Air
24c.For Water Supply&IrIjection 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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Fomr GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterIResources Revised August 2013