GW1--05128_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 310 ft 329 ft 6gpm
2465-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Bumble)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 131 ft 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22-367 FROM TO DIAMETER THICKNESS MATERIAL _
2.Well Construction Permit#: ft. ft. is
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
ftt, ft. in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fl. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite Pumped
Injection Well: It. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R
❑Aquifer Test ❑Stormwater Drainage R R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain nee,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fit. 40 ft- Brown Dirt
7/5/24 40 ft. 110 ft. Brown Rock
4.Date Well(s)Completed: Well IDtt
110 ft- 345 ft* Slate
5a.Well Location: ft, ft
Pinnacle Homes USA, LLC
ft ft- Seams: 175', 195',210',217',235',260',
Facility/Owner Name Facility ID6(if applicable)
ft.. ft. 272',
Vann Sneed Rd., Marshville 28103 (Lot 4) 310-329'=6g
ft. ft.
Physical Address,City,and Zip 21.REMARKS s i•
Union 03-111-025D
County Parcel Identification No.(PIN)
AUG d's 0 424
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) In.f.,,7.-A ,1-..-^:r-":'•, I.ii`
N W �e G(� y S�� yccd ' 11124
Sidi ire of Certified Well ContractorCl 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 1 SA 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: 345 (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 1@100) construction to the following:
30
to.Static water level below top of casng: (ft.) Division of Water Resources,Information Processing Unit,
i
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Well(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.anger,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) 6 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013