GW1-2022-10036_Well Construction - GW1_20221107

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
14.
Dwight L. Huneycutt FRWATERzoNEs
� gg FROM TO DESCRIPTION I i
Well Contractor Name r r�, .+ s �+1 8 : 207 ft- 215 tt- I i! 2 9pm
4070-A n ry 2022
ft ft.
NC Well Contractor Certification Number N O V a ! L O 2 2 15.OUTER CASING.for mu1t1 ged wells OR LINER if a licable
FROM TO DLAMETER THICTflNESS MATERIAL .
Derry's Well Drilling, Inc. ifrror on Procw��j:,g Una 0 ft. 157 ft 6 1/8 in SDR-21 I PVC
Company Name Liv-S.UncrG 16.INNER CASING OR TUBING cothermal•closed-loo .
22-33 FROM TO I DIAMETER I T111cfaims MATERIAL
2.Well Construction Permit#: ft. ft in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fL iv
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROMI TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 sr' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft 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. fr.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To I DESCRIPTION color,hardness,soillrock type,grains etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 D• Brown Dirt
4.Date Well(s)Completed: 4/8/22 Well ID# 15 ft 32 ft. Brown Rock
32 ft 460 ft Slate
Sa.Well Location: ft ft.
Pinnacle-Homes USA, LLC u. ft
Facility/Owner Name Facility III#(if applicable)
5014 Tom Starnes Rd., Waxhaw 28173 ft ft. Seams.: 95',116',150', 199 207'=2gpm
ft ft. ,
Physical Address,City,and Zip 21.REMARKS
Union 05-020-011
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshainutes/seconds or decimal degrees: 22.Certification: !
(ifwell field,one latllong is sufficient)
N W !oV i 4/30/22
Signature of Certified Well Contractor ! I Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the 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 IZ]No 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#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: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 2@100) construction to the following: f
I
10.Static water level below top of casing:
48 (ft) Division of Water Resources,Information Processing Unit,
Ifmvaterlevel is above casing,use"+^ 1617 Matz Service jCenter,Raleigh,NC 27699-1617
1 ,
6 11.Borehole diameter. (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
__
24a above, also submit a copy I fl;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) 2 Method of test Air 24c.For Water.Supply&Injection Wells:
Also submit one copy of,this I foim 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 W I Resources Revised August 2013
I