GW1-2022-10069_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 F4.wATERzoNEs O f
FROM TO DESCRIPTION.
Well Contractor Name 196 f' 200 ft. t gpm
4070-A 3- a ' ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER TIHCI 'V MATERIAL
Derry's Well Drilling, Inc. N0V 01 20Z2 0 M 157 ft 61/8 !!"" I SDR-21 I PVC
Company Name q 22 16.INNER CASING OR TUBING, eolhermal closed-loop)
UrtY. FROM TO DIAMETER I THICKNESS MATERIAL.
2.Well Constriction Permit#: O' ' ' r fa ft. ft in
List all applicable well permits(i.e.County,State,Variance, njection,etc.)
ft. ft .in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 a 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
D. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
El Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness soiprock type,grMn siie,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 24 ft Brown Dirt
4/7/22 24 ft. 48 & ! Brown Rock
4.Date Well(s)Completed: Well ID# 48 ft 405 ft- Slate
5a.Well Location: ft. ft
Pinnacle Homes USA, LLC rc
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams: 66', 190', 196'=19pm
5022 Tom Stames Rd.,Waxhaw 28173(Buck Acres Lt 8) ft ft
Physical Address,City,and Zip
21.REbfARKS
Union 05-020-010
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) / !'
5/2122
N w
Signature of Certified Well Contractor Date
6.Is(are)thewell(s): OPermanent or ❑Temporary By signing this form,I hereby certify that,the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ZINo 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 421 remarks section or on the back of thisform. 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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of tl{is!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) 1 Method of test: Air 24a 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resouices Revised August 2013
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