GW1-2022-04276_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
John W. Huneycutt FROM TO DESCRIPTION
Well Contractor Name Y _Y :� �' _ 495 ft' 498 ft. 60 gpm
" .
2465-A It. ft.
NC Well Contractor Certification Number APR 0 8 2022 IS.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ;. 0 ft 49 ft- 6118 in SDR-21 PVC
Company Name - "• 16.INNER CASING OR TUBING(geothermal closed-loopl
i ,ivc,`.�`,;+; FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#• 21-126:'a"' ft. ft in
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
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑iri ation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 fr. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑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
❑Experimental Technology ❑Subsidence Control It. ft
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,wiVrock type,prain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It. 10 ft. Brown Dirt
12/29/21 10 ft. 34 ft Brown Rock
4.Date Well(s)Completed: Well II)#
34 ft. 500 ft. Blue Rock
5a.Well Location: ft. ft
Pinnacle Homes USA ft ft.
Facility/Owner Name Facility ID#(ifapplicable)
IL ft Seams: 59',89', 108', 135-140', 180',
5104 Tom Starnes Rd, Waxhaw 28173 (Buck Acres Lt7)
ft ft 215' 245',265',292',380',495'=609
Physical Address,City,and Zip
21.REMARKS
Union 05020009
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/iong is sufficient)
N W 1/20/22
ature of Certified Well Contractly Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZJNo copy ofthis 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 q/'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 ON1,Y with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 29 (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 24b.For Infection 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:
(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) 60 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013