GW1-2021-04547_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or nnthiple wells
1.Well Contractor Information:
nk
Dwight L. HuneycuU 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 515 n• 520 r'• 1 gpm
4070-A 9 'L01, ft. n.
NC Well Contractor Certification Number Pp(�` " VA 15.OUTER CASING for mu1N-cased wells OR LION R if a llcable _
CO�ec0\q FROM TO nIA�rETER nu IREss MATERIAL
Derry's Well Drilling, Inc, enp t•3`0I\ 0 f6 50 n 6 1/8 h"• 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-475 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I h• ft. 1 In.
List all applicable well perniits(i.e.County,State,1,briance,Injection,etc.)
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. h. ln.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n• n• In.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL.! EMPLACEMENT METHOD&AAfOUNT
[]Irrigation 0 ft' 3 rt. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 h' 35 rc' Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
n. rt.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG fattacIt additional sbeets if necessary)
❑Gcothetmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solVrock type,Vain sin,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain wider#21 Remarks 0 ft. 18 ft. Brown Dirt
12/14/2Q 18 ft- 600 ft. Blue Granite
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. rt.
Pinnacle Homes USA rt. rt.
Facility/Owner Name Facility IDh(if applicable) rt. n• Seams: 58', 167',233',428', 515'=1 g
9201 Providence Rd S, Waxhaw 25173 n n•
Physical Address,City,and Zip 21.REMARKS
Union 05051006Q
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lavlong is sufficient)
N W � t-,L� �GCj1.Qeytc c 1/2/21
Sigrratttre oPCcrtified Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this formr,I hereby certify that the wells)it-as(were)constructed in accordance
with 15.4 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 I7JNo copy of this record has been provided to thejwell owner.
If this is a repair,fill out kno of irell construction information and explain the nature of the
repair tinder#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 wells ONLY with the sane construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ex•anple-3@200'and 2 cal 00') construction to the following:
35 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: In'addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary construction to the following: s
(i.e,anger,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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 Method of test: Air Also submit one copy of this form within 30 days of completion of
13b.Dlslnfectlon type: Amount: 1/Z lb,Granular well construction to the county health department of the county where
constructed.
j
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013