GW1-2023-01612_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD
i
For Internal Use ONLY:
This form can be used for single or multiple wells I!
1.Well Contractor Information:
14.�VATERZONES
Derry L. Huneycutt
FROM TO DESCRIPTION
Well Contractor Name 107 ft. 110 ft. I I 79Pm
2663-A 150 ft 155 ft 4 8 9Pm
NC Well Contractor Certification Number
�^ 0 ° r.a49 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETEN I THIC"Ess MATERIAL
Derry's Well Drilling, Inc. FEB ti 2023 0 ft 70 ft 61/8 f i SDR-21 I PVC
Company Name 1;r,1 16.INNER CASING OR TUBING eotbermal closed-loo
22-11gn�i+:F.` r:+f - FROM To DLUNETERI IMC109M MATERIAL
2.Well Construction Permit#: r,1c•tt7;'%,?? fr. ft.
List all applicable well permits(.a County,State,Variance,hieaiion,etc.) R. ft. hal
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) it ft. in t'
i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 f4 20 ft Bentonite' Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a licable
FROM TO MATERIAL ii EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑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 color,hardness,soi0rock typN grain size,etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 10 ft. Red Dirt
4.Date Well(s)Completed: 10/26/22 Well ID# 10 ft, 20 ft j Brown Dirt
20 ft- 40 ft. Boulders
Sa.Well Location: 40 fL 205 ft- Blue Rock
Pinnacle Homes USA, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft
5717 Rehobeth Rd.,Waxhaw 28173(Jackson Hole, Lot 6) ft.
ft. Seams:75',86', 107'=7gpm, 150'=8 gpm,
ft. 190'
Physical Address,City,and Zip 21 REMARKS
Union 05147041F
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: !;
22.Certification:
(ifwell field,one lat/long is sufficient)
N W � z— � � 11/18/22
Signature of fled Well Contractor V Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary By signing this fornx I hereby certify that the well(s)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 ofdus record has beenprovided 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
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 with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of using: 22 (ft,) Division of Water Resource's,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- 6 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary. 24a above, also submit a copy of this i oim 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 276994636
13a.Yield(gpm) 15 Method of test: Air 24c.For Water Supply&Injection Wells.
Also submit one copy of this form wiihiir 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013