GW1-2021-00824_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
R F
Dwight L. Huneycutt WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 250 ft. 260 It. 2gpm
4070-A ft. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 46 It 61/8 im SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-Ino
21-119 FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. It. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
I, it. in.
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 is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 IL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 ft 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑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. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock typr,grain sra etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fL 19 & Brown Dirt
4.Date Wells)Completed: Well IDll
9/28/21 19 It- 25 ft. Brown Rock&Quartz
25 ft. 400 ft. Slate
5a.Well Location: fL fL
Pinnacle Homes USA, LLC ft. M
Facility/Owner Name Facility ID#(if applicable)
5108 Tom Starnes Rd,Waxhaw 28173 (Buck Acres Lt5) ft. & Seams:55',59',,11T, 154';;169:; E;
IL ft. 174',250'=2g,31-0' '
Physical Address,City,and Zip 21 REMARKS
Union 05-020-007
County Parcel Identification No.(PIN) r ; VySi
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.
� { 1
(if well Field,one laUlong is sufficient)
N W (/ 10/12/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thatthe 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 FIND 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 921 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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 48 (ft•) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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: Rotary 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
24c.For Water Supply&injection Wells:
13a.Yield(gpm) 2 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
f