GW1--05034_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
I.Well Contractor Information: ,
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION •
Well Contractor Name _ 70 ft. 80 ft• 60 gpm
:C.:. : C r
2465-A i�, t 92 ft. 115 ft 15 gpm
NC Well Contractor Certification Number AUGi 0 t•t O rl[ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.limbic)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well.Drilling, Inc. o ft- 45 ft• 6 1/8 "L SDR-21 PVC
�rC2zor : Liti� - - l l
's^"""'�� � '� 16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name ln+u�'�`���-i1( '
23-96 owns. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(Le.County,Stale,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 ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL EMPLACEMENT &METHOD AMOUNT
❑Irrigation 0 ft. 3 ft- Bent.Chips Gram
Non-Water Supply Well: •
OMonitoring ❑Recovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: it ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery .0 Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 25 ft- Brown Dirt&Rock
5/17/23. 25 ft• 125 ft- Slate
4.Date Well(s)Completed: Well ID# -
ft. ft.
5a.Well Location: ft. ft.
Pinnacle Homes USA, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Lone Eagle Dr.,Monroe 28110(Watson Glenn,Phase Ill,Lt 38) - ft. ft. Seams:57',70'=60 gpm,
ft. fL 85',92-107-115'=15 gpm
Physical Address,City,and Zip 21.REMARKS
Union 08048055
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 9 W. 6/10/23
Signs of Certified Well Contractor Date
6.Is(are)the well(s); ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 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#21 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-crater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (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 2C4)100) construction to the following:
10.Static water level below top of casing: 1 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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:
(ie.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)75- , Method of test: Air- 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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