GW1-2021-00823_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES
cu
9 Y FROM TO DESCREPTION
Well Contractor Name 210 ft- 220 ft I 2gpm,
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licahle
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 45 ft 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING Nithermal dosed-loo
21-120 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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 THICKNESS MATERIAL
❑Agricultural ❑MunicipaYPublic ft• ft• m,i
❑Geothermal(Heating/Cooling Supply) R3Residcntial Water Supply(single) ft ft m.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 3 ft- Bent.Chips Gravity
Nan-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: fL ft
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK if applicible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT -IHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gnin sim,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft• 6 ft. Wet Brown Clay
9/30/21 6 ft. 18 ft. Brown Dirt
4.Date Wells)Completed: Well ID#
18 IL 26 FL Brown Rock
5a.Well Location: 26 ft 400 ft• Slate
Pinnacle Homes USA, LLC fc ft.
Facility/Owner Name Facility 1D#(if applicable) ft, fL Seams:53', 109', 116',210'=2g,
5112 Tom Starnes Rd, Waxhaw 28173 (Buck Acres U4) ft, ft 354_ 59 �� l i-- r
Physical Address,City,and Zip 21.REMARKS T -°
Union 05-020-006 QEC 0
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
a zt,L.
N w � 10/12/21
Signature o leertified Well Contractor Date
6.Is(are)the well(s): ©Permanent 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 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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#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
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: 400 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii fereru(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing- 49 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
1t.Borehole diameter- 6 (in.) 24b.For Iniection 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:
(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 276994636
13a.Yield(gpm) 2 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 health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013