GW1--02769_Well Construction - GW1_20240507

i'
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information: "
Dwight L. Huneycutt FRWA
'ERZ°n'Es TO DESCRIPTION;
Well Contractor Name v--i-, .r), s"��,_ 90 it 95 ft. I I 6 gpm
4070-A k,to..k•.r�i.:i 'iz•I ;,_,,1f 171 ft 178 ft I I 6 gpm
NC Well Contractor Certification Number MAY v i c024 15.OUTER CASING(for multi-cased wells)OR LINER(if ap !Roble)
FROM TO DIAMETER, THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 66 ft 61/8 SDR-21 PVC
�__
Company Name lPr:�:�i.•.:ti.i? :':'^s.^•4.`.;;y i„)l.;X 16.INNER:CASING OR TUBING(geothermal closed-loop)
23-307 G`L�rO.:t,..)0 R FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. f. ;in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE —THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control -
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft• 17 ft Red Clay
4.Date Well(s)Completed: 2/9124 Well ID# 17 ft. 44 ft. Brown Dirt
44 ft. 57 ft. Brown Rock
5a.Well Location: 571 ft 225 f• Slate
Pinnacle Homes USA, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) Sea HIS:72,79,83,90-6g, 133, 154,,
ft. ft. 171'=6g
5805 Stack Rd., Monroe 28112 ft. ft - i,
Physical Address,City,and Zip 21.REMARKS
Union '03-159-005E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W Z7G " 2/28/24
Signature of Ctrtified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or OTemporary By signing this form,I hereby cert fy 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 EiNo 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS !
9.Total well depth below land surface: 225 (f(,) 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: I
10.Static water level below top of rasing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel 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
Rota 24a above, also submit a copy of this;form within 30 days of completion of well
12.Well construction method: ry 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) 12 Method of test: Air 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. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013