GW1-2021-00841_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:
John W. Huneycutt FFR MATERZONEs TO I DESCR81 ON
Well Contractor Name 87 B' 100 H• 3 gpm
2465-A 193 n• 200 rt 1 7 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multicased wells OR LINER if a Rcable
FROM TO DIAMETF3t THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 70 D 6 1/8 tO SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-81 FROM TO DIA11tETE I TMCKNI SS MATERIAL
2.Well Construction Permit#: ft• ft• in
Cut 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 SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic ft. ft. in.
❑Geotherml(Heating/Cooling Supply) ®Residential Water Supply(single) M' B• in.
❑Industrial/Comnicrcial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EUPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 3 D• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 R' 35 B Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery Salinity Barrier FROM TO DfAT11tIA1. EMPLACF11tF.N1 aLETHOD
❑
ft. tt.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,luirdness,soil/rock type,grain sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 12 n• Red Dirt
4.Date Well(s)Completed: 8/16/21 Well ID# 12 D 31 D• Brown Dirt
31 D 55 D• Brown Rock
5a.Well Location:
Pinnacle Homes USA, LLC 55 ct 225 n Blue Rock
ft. ft. b
Facility/Owner Name Facility ID#(if applicable)
n• D• Seams:79',87-10 4'
5619 Rehobeth Rd., Waxhaw 28173 (Lot 1)
n n 143',193'=7g t
Physical Address,City,and Zip 21.REMARKS
Union 05-147-041 A
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Ce cation:
(if well field,one lat/long is sufficient) ', / /
N Wyz& (�/ lC1V 9/14/21
Signd&of Certified Well C mtractor Date
6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing this form,I hereby certify that the rvell(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 e4dsting well: ❑Yes or �No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the"attire 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 (ft.) 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:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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) 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: 1/2 lb. well construction to the county health department of the county where
constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013