GW1-2023-02683_Well Construction - GW1_20230411

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
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9 Y FROM TO DESCRIPTION
Wel►ContractorName - -�, 136 f`. 139 ft I 14 gpm
4070-A v,..."; ' ''. 174 fw 180 ft- j 4 gpm
NC Well Contractor Certification Number APR j 2 �� "15.OUTER CASING for multi-cased wells OR LINER ifs licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling,Inc. o ft. 62 ft.
61/8 SDR-21 PVC
Company Name t^..,;h=•••.•,-,-�, , "J ' 16.INNER CASING OR TUBING fimothermat closed-loop)
- ^—�^� FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 365814 ft. ft. m
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 ❑Municipal/Public % ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. it. is
❑Industrial/Commercial ❑Residential Water Supply(shared) =18:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 20 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soil/rack type,grain s m,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft- 22 ft. i Brown Dirt&Rock
4.Date Well(s)Completed: 1/17/23 well ID# 22 ft 225 ft Slate
ft. &
5a.Well Location: ft: ft
Pinnacle Homes USA LLC
Seams:57',62'=1/2gpm,69',81',88'=2gpm
Facility/Owner Name Facility ID#(ifapplicable) ft ft
ft ft 97'; 115', 129', 4gpm9'=12gpm,
Ridgecrest Rd, Locust 28097 (Lot 1)
ft. ft. 174'= gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 447
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 2/14/23
Signature of ert►fied Well Contractor V Date
6.Is(are)thewell(s): OPerrnanent 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 and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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#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 INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdilferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 25 (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 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
139.Yield(gpm) 18 Method of test• AI r 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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