GW1-2021-00817_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts
1.Well Contractor Information:
John W. Huneycutt 14.WATERZONES
Y FROM I TO DESCRIPTION
Well Contractor Name 190 ft' 196 ft- 10 gpm
2465-A
NC Well'Comractor Certification Number 15.OUTER CASING for multicased wells OR LINER ifs licable
FROM TO DIAMETERI THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 64 ft' 6 1/8 In. I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-80 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft- ft• 'in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) in.
3.Well Use(check well use): 19.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
ft. ft. it,
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooting Supply) OResidential Water Supply(single) ft• ft• [n.
❑lndustriaUCommereial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irr; ation 0 ft' 3 rl Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring []Recovery 3 ft• 35 ft• Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL' EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier � ft
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tr'acer FROM TO DESCRIPTION color,hardness,solltrock in sin etc.
❑Geothermal(Heatin Coolin Rctum ❑Other(explain under#21 Remarks 0 ft- 8 ft. Red Dirt
8/14/21 8 ft- 26 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
26 ft' 47 ft. Brown Rock
So.Well Location: 47 ft• 205 ft Blue Rock
Pinnacle Homes USA, LLC
Facility/Owner Name Facility lD#(if applicable) R. [L 1` i
Seams:76',87;�10;�135;-150j,i,-- 1
Rehobeth Rd., Waxhaw 28173 (Lot 2) ft• ft•
190'=1
Physical Address,City,and Zip 21.REMARKS
Union 05-147-041 B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field one Jai/long is sufficient) J 1�
N W �w• j'r 9/14/21
Si of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certif},that the ivell(s)was(were)consinicted in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the ivell owner.
Ifthis is a repair,fill out known well consmiction information and explain the nature of the
repair tinder#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
&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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
if rester 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 24aabove, also submit a copy of thus form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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• 112 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Caroline Department of Environment and Natural Resources—Division of Water Resources Revised August 2013