GW1-2022-10056_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
1.Well Contractor Information: i
Dwight L. Huneycutt FR.wATERzoNES >' 'ROM TO I DESCRIPTION I
Well Contractor Name a 250 ft 260 ff I I I 7 gPm
%4070-A f a ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER if a Gcahle
0 7 2022 FROM TO DIAMETER TIICIINFSS MATERIAL
Derry's Well Drilling, Inc. NOVY . 0 ft 160 ft 61/8 t°' ] SDR-21 PVC
Company Name r ,fig;^1 Pro SAi? k` 16.INNER CASING OR TUBING eothermal closed-hui
tf*C+r =�'`�''21-288 > FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Constriction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICIdVFSS 1HATEIIAL
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Elhri ation 0 ft 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 n Bentonite; Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
I. ft
❑Experimental Technology ❑Subsidence Control
20.DRILL ING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soflfrocktype sim,ea.
[]Geothermal(Heating/Cooling Retum) OOther(explain under#21 Remarks) 0 ft 27 ft. Brown Dirt
4.Date Well(s)Completed: 3/17/22 Well ID# 27 ft 51 ft Brown Granite
51 1't 300 ft Blue Granite
5a.Well Location: ft ft
Pinnacle Homes USA ft. ft
Facility/Owner Name Facility 1D#(if applicable)
5707 Rehobeth Rd,Waxhaw 28173(Jackson Hole W) ft ft Seams: 6T,75',98', 176',190-193',
it ft. " 250'=7gpm
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Physical Address,City,and Zip 21.REMARKS
Union 05-147-041 C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one lathong is sufficient) / I
N W 5/12/22
Signature oirCertificdWell Contractor I' Date
6.IS(arc)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 allo copy ofilds record has beenprovided to dreavell 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
S.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 INSTUCPIONS
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9.Total well depth below land surface: 300 (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@100) construction to the following:
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10.Static water level below top of casing: 41 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Cen I,ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending,the form to the address in,
74a above, also submit a copy of this form within 30 days of completion of well
Rotary
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 Wm) 7 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 healih(department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of,Water Reno i Revised August 2013
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