GW1-2022-10055_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt ,j -.. FR.wATERzoNEs 6 i
�.,`""'" ft_ a Z �'y__. FROM TO DESCRIPTION I
r a s m. a 1.e I!—L.,' 358 ft 365 ft. � 2 9Pm
Well Contractor Name � Q�*
4070-A NOV. 0 7 2022 ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LiNER if 'cable)
FROM TO DIAMETER THICKNESS .MATERIAL
Derry's Well Drilling, Inc. In£TMaV,2�'hc`"'�ng Dn`I 0 ft 166 rt 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
p r�
21-289 FROM TO DIAMETER!' THICKNESS MATERIAL
2.Well Construction Permit#: tt ft. is
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 TMCKNESS MATERIAL
ft & in.
❑Agricultural ❑Municipal/Public
fL 'ft
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
im
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge l7Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
[]Aquifer Test ❑StormwaterDrainage ft iz
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardoess,suillrock type,grain sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other explain under 421 Remarks 0 ft, 25 rt ; Wet Sandy Dirt
4/13/22 25 ft 47 rt 1. Brown Dirt
4.Date Well(s)Completed: Well ID# i
47 ft 60 ft 1; Brown Granite
5a.Well Location: 60 ft 400 ft Blue Granite
Pinnacle Homes USA rt rc
Facility/Owner Name Facility III#(if applicable)
5711 Rehobeth Rd,Waxhaw 28173 (Jackson Hole Lt4) ft Seams: 80-83', 119', 156', 174',228',
ft. ft 270',358'=2g,379',390'
Physical Address,City,and Zip 21.REMARKS
Union 05-147-041 D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ;2.Certification:
5/12/22
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or []Temporary By signing this form,1 hereby cert fy that the svell(s)rvaa(were)constructed in accordance
ivith 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 DNo ropy ofthis record has been provided to rite,well owner.
If this is a repair,fill out known well construction information and explain the nature of the I
repair under#21 remarks section or on the back ofthis farm. 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 ivells ONLY with the same construction,you can
submit one fora. 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 ifdifferent(example-3 t@200'and 2@100) construction to the following:
53 Division of Water Resources,Information Processing Unit,
f Static water level below top of casing: (R) 1617 Mail Service Center,Raleigh,NC 276994617
ljwater level is above casing,use"+" I ; g
11.Borehole diameter:
6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this-form within 30 days of completion of well
12.Well constriction method Rotary construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Iniection I.Wells:
Also submit one copy of this form iwithin 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.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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