GW1-2021-00835_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:
Dwight L. Huneycutt 14.WATERZONE5
g Y FROM TO I DESCRIPTION
Well Contractor Name 193 fL 200 fi- 1 7 gpm
4070-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CING for mulaedwels OHI a icable
FROM DMTR MATERIAL
Derry's Well Drilling, Inc. 0 ft. 46 ft- 6 1/8 in SDR-21 PVC
Company Name A 16.INNER CASING OR TUBING eothermal closeddoo
20-473 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n• h• 1n.
List all applicable well permits(r.e.Counlyt State,Variance,Injection,etcj
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 iL Bent.Chips Gravity
Non-Water Supply Well:
3 ft 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
FROM TO I 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 tf necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Color,hard as,soiVroek tyM grain sir,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 ft. Brown Dirt
4.Date Well s)Completed: 6/16/21 Well ID# 16 fL 28 ft Junky Rock
( p 28 ft. 225 ft. Blue Granite
Sa.Well Location: ft. ft.
Pinnacle Homes USA fL it
Facility/Owner Name Facility ID#(ifapplicable) ft fL
9119 Providence Rd S,Waxhaw 28173(Simpson Acres Lt4) Seams:50',70',95', 135', 157', 171',
Physical Address,City,and Zip 21.REMARKS
Union 05051006N ULC 08 ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(ifwell field,one lottlong is sufficient)
N W A ,L 7/10/21
Signature Well Contractor Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary By signing this form, I hereby certify that the well(s)w•as(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 END copy ofthis record has been pmvuled to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under r21 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-waler supply wells ONLY with the.came construcdoin,you can
submit cme form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 43 (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: 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
13a.Yield(gpm) 7 Method of test: Air 24o 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.
i
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013