GW1-2023-01613_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Der L. Huneycutt 14.WATERZONES E ;
Derry Y FROM TO DESCRIPTION
Well Contractor Name '' . ? - 1 147 it 150 fr I I 2 9Pm
2663-A �` �: ft. &
NC Well Contractor Certification Number F E� ti 2023 15..OUTER CASING for multi-cased wells iOR LINER if a livable
FROM TO DIAMETER f I .L--ESS MATERIAL
Derry's Well Drilling, Inc. �r ; l;n:o ft' 75 ft 61/8 is SDR-21 I PVC
Company Name
i�rrtr:rw-", t�L� 16.INNERCASINGORTUBING(geothermal closed-loop)
�v'e FROM TO DIAMETER I + THICKNESS MATERIAL
2.Well Construction Permit#: 22-115 fL 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 51ATEPJAL
OAgricultural ❑MunicipaUPublic ft ft in
❑Geothermal(Heating/Cooling Supply) PIResidential Water Supply(single) f, ft. in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT 51ETHOD&AMOUNT
[]Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 ft- Bentonite; Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
FROM TO MATERLIL I� EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
I ,
❑Experimental Technology ❑Subsidence Control ft. fr.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock 'n sba,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 60 fr. Brown Dirt&Sand
10/22/22 60 fL 405 is Blue Rock
4.Date Well(s)Completed: Weil El)# ft. ft.
5a.Well Location: f. ft.
Pinnacle Homes USA, LLC u
ft. ft
Facility/Owner Name Facility M#(if applicable)
5713 Rehobeth Rd. Waxhaw 28173 (Jackson Hole, Lot 5) ft. ft. Seams:; 1 , 116',120',127', 134',
' fr. fr. 147-150''=2gprnm,210',230',250',265'
Physical Address,City,and Zip 21.RENIARKS
Union 05147041 E
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwcU field,one lat/long is sufficient) ,,(�
�Qi?iLN � Y f 11/18/22
N W
Signature ofCcrf&cd Well Contractor V Date
I'
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the' ivell(s)was(were)constructed in accordance
with I5A 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 ❑No copy of this record has been provided to the iv,ell owner.
If this is a repair,fill out known well construction information and explain the nature of the i'
repair under#21 remarks section or on the back of this fortm 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 ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,(Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary. 24aabove, 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,Under ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013