GW1-2021-04544_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD
For huntwl Use ONLY:
This form can be used for single or andtiple wells
1.Well Contractor Information: i
Dwight L. Huneycutt G s� 14,WATER ZONES ez 'i L172f-
TO DESCRIPTION
Well ContractorNane % O,t, 178 rr• 12 gpm
4070-A 2 9 1 . ft.
NC Well Contractor Certification Number 1F5ROOUTER CTOSING for mu rDIA*�sedwells OR�ISIS a R b�lnter.
TER
Derry's Well Drilling, Inc. ctf•���� Sec° 0 rt• 45 n 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
20-474 FROM To DIAMETER T 11MINTSS nfATERIAL
2.Well Construction Permit#: ft. TO
In.
List all applicable well permits(i.e.Counpt State,variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I ISLOTSIZE THICI.NT.SS MATERIAL
❑Agricultural ❑MunicipalTublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD d AAIOUNT
❑Inri ation 0 n. 3 n• Bent. Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 ft- 35 n• Bentonitel Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO AfATERIAL I EMPLACENIENTAfETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Storrawater Drainage
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional sheets Itnecessam
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock a in size etc.
❑Geothennal (Heating/Cooling Return []Other(explain under 021 Remarks 0 tt. 9 ft. Brown Dirt
12/12/20 g rt. 16 n Brown Rock
4.Date Well(s)Completed: Well ID#
16 rr• 265 rr• Slate
So.Well Location:
i
Pinnacle Homes USA
Facility/Owner Name Facility ID#(if applicable)
9123 Providence Rd S, Waxhaw 28173 Seams: 88', 115', 130', 172'=12g
Physical Address.City,and Zip 21.REMARKS
Union 05051006P
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one W/long is sufficient)
N W �iotr� 1/e
2/21
Signature oi'C ified Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby cert fi,that the w•ell(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NC9C 02C.0?00 Well Construction.Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill our krona n•ell 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 u-iih the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n•ells list all depths if ifi ereru(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Witter Resources,Information Processing Unit,
If water level is above coring,use"+" 1617 Alail Service Ceti ter,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: hit 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) 12 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fonn�within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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