GW1--05050_Well Construction - GW1_20230804

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
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This form can be used for single or multiple wells
1.Well Contractor Information: •
Dwight L. Huneycutt 1144.WMATER ZONES DESCRIPTION
Well Contractor Name i. �-„ �ti 117 ft• 125 ft 6 gpm
4070-A +....L0 t_ $'1�'E, ft. ft. ; ;
NC Well Contractor Certification Number n r 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
AUG _ 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 44 ft• 6 1/8 , in- SDR-21 PVC
Company Name intouralc.n Prnr f, .,X, iit`4 16.INNER CASING OR TUBING(geothermal closed-loop)
23-25 Del fc .1�i a FROM TO • DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits 0.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
H. ft. .in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) LlResidential Water Supply(single) ft it in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 ft. Bent.Chips Gravity '
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 ft• Bentonite Pumped
Injection Well: ft. ft..
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) .
FROM TO MATERIAL 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)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sirs etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 12 ft• Brown Dirt
4.Date Well(s)Completed: (O'° "Well ID# 12 f 300 ft Slate
ft. ft.
5a.Well Location: ft ft
Hailey&Cameron Dorton ft ft. Seams: 110', 117'=6gpm,210'
Facility/Owner Name Facility ID#(if applicable)
ft ft 212'
7107 White Store Rd, Marshville 28103, ft. ft.
Physical Address,City,and Zip 21.REMARKS ,
Union 02129001C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in d ees/minutes/seconds or decimal degrees: 22.Certification: )
(if well field,one lat/long is sufficient) i��'�i'�'- �(/
N w ��� � r ' et- 7/25/23
Signature of Ce ed Well Contractor Date
6.Is(are)the well(s): ©Permanent r ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA 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#2I 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 censtruetlon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (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@100) construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
' If water level 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
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12.Well construction method: ry construction to the following:
(ie.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 27699-1636
13a.Yield(gpm) 6 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 GW4 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013