GW1--07692_Well Construction - GW1_20231122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 210 ft, 215 ft I ! 5•gpm
4070-A 238 ft. 242 ft. I , 10 gpm
NC Well Contractor Certification Number -IS.OUTER CASING(for multi-cased wells)OR LINER(if ap livable) -
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 68 ft. 61/8 in. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) --
22-369 FROM TO DIAMETER . THICKNESS MATERIAL
. 2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Couny,Stale,Variance,Injection,etc.) -
ft. ft. r in.
3.Well Use(check well use): 17:SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.❑Agricultural OMunicipal/Public ft in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. ,in
❑lndustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft* Bent Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK(if applicable) - - - . -„ - •------
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO•• MATERIALEMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach'additional sheets if-necessary) • "' •
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 32 ft. Brown Dirt
4.Date Well(s)Completed: 8/24/23 Well ID# 32 ft- 210 ft- Brown Rock
210 ft. 300 ft. Blue Rock
5a.Well Location: - ft. ft.
Pinnacle Homes USA, LLC . ft• ft.
Facility/Owner Name Facility ID#(if applicable)
ft• ft Seams: 167',181',210'=5g,221',
3921 Vann Sneed Rd, Marshville 28103 (Lot#2) ft, tr. 229',238-242'=log _
Physical Address,City,and Zip 21.REMARKS - -- - • - -: : - : •, s 77s_
Union 03-111-025B -4,.:-r,I '� I 1
County Parcel Identification No.(PIN) NI I I V 2 2 ?1,a
5b.Latitude and Longitude in degrees/mintites/seconds or decimal degrees: 22.Certification: J
(if well field,one lat/long is sufficient) :; :'• ^- ,.
9/15/ ci.=',`>W;;
N W Signature o Certified Well Contractor . Date
6.Is(are)the well(s): WIPennanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EIN0 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
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 forni SUBMITTAL INSTUCTIONS
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 if different(example-3@200'and 2Q100) construction to the following:
I.
10.Static water level below top of casing: 30 (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 Infection Wells ONLY: IIn 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: j '
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Air
24c.For Water Supply&Injections 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 hmidtb department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013