GW1-2022-10076_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:
14.WATER ZONES P.
Dwight L. HuneycuttE ,��``n' a- � oM To DESCRnPTION
Well Contractor Name '137 ft. 140 ft. I I 4 gpm
4070-A NOV 0 7 2022 11 %
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased"wells OR LINER if a Gcable
intor� &Vi3n f ri Ct� g U i FROM, TO DIAMETER I TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. DV'.U/B0G 0 ft 45 ft. 61/8 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING 6fliermal closed-loon)
2 FROM TO DIAMETER ' THICKNESS MATERIAL
22-3
2.Well Construction Permit#: 2 ft ft. +,; in.
List all applicable well permits(i.e.County,'State,Kiriance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ti, in. I
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. & in.1
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM ITO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f`- 20 ft. Bentonite Pumped
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.TO 11tA7 RRIAI. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION colon hardness soiumek typc in sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ' ft• 31 ft. Brown Dirt
ft ft
4.Date Well 7/29/22 s)Completed: Well ID# 31 37 Brown Rock
37 ft 305 ft• Slate
5a.Well Location: ft. ft.
Pinnacle Homes USA, LLC
ff. ft
Facility/Owner Name Facility ID#(if applicable)
5020 Tom Starnes Rd., Waxhaw 28173 ft. ft. Seams:85', 111', 137-140'=4gpm
ft ft.
Physical Address,City,and Zip 21.REMARKS
Union 05-020-014
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(ifwell field,one lat/loug is sufficient) /
N W t�Gflrt�l"__ L. 8/31/22
Signature ofCcrTified Well Contractor V Date
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6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that die well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [-]Yes or 1ZlNo copy ofthis record has been provided to the'well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis 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-wafer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft) 242. For All Wells: Submit this fiirm within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 1®100) construction to the following: I' '
10.Static water level below top of using: 48 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Injection Wells ONLY: htI 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.Anger,rotary,cable direct posh etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center;Raleigh,NC 27699-1636
4 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resource RevisedRevised August 2013
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