GW1--07678_Well Construction - GW1_20231122

I
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.WATER ZONES,'. - z 1
g y FROM TO DESCRIPTION
Well Contractor Name 250 ft 255 f4 I 4 gpm
4070-A 268 ft 275 ft• I , 4 gpm
NC Well Contractor Certification Number
15.OUTERCASING(formulti•casedwells)•ORLINER(ifap licable)'-
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 44 ft 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothe•malclosed-loop) `` `' '
22-319 FROM TO • DIAMETER li THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i I.
list all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. h in.
3.Well Use(check well use): 17.SCREEN. _
Water Supply Well: '- FROM TO DIAMETER SLOT SIZE THICKNESS' MATERIAL
❑Agricultural— ❑Municipal/Public ft. ft. in
❑Geotbennal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in I'
..18.GROUT '
❑Tndustrial/Commercial ❑Residential Water Supply(shared) roots To MATERIAL'h EMPLACEMENT METHOD&AMOUNT
❑hrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft- Bentonite;, ' Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :1 9.SAND/GRAVEL PACK(if applicable): • - - •
FROM TO . MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft>
❑Aquifer Test ❑StormwaterDrainage ft. ft. i
❑Experimental Technology ❑Subsidence Control 1
.20.DRILLING LOG(attach additional sheets if necessary) '.;•< ' .:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,h rdness,soiUrocktype,gainsize,ett)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 14 ft. I Brown Dirt Rock
8/14/23 14 it 300 ft• Slate
4.Date Well(s)Completed: Well ID# - -- -
ft. ft
5a.Well Location: • ft. ft. ,
Michael&Teresa Treadaway ft. ft
Facility/Owner Name Facility IDt1(if applicable)
4110 Whispering Pine Dr., Marshville 28103 (Lot 3) ft Seams:62',81', 114', 176',211',
e. ft. 250'=4gpm,268'=4gpm;.
' q ,>.
Physical Address,City,and Zip 21.REMARKS � ,i-) ,,'. is`` '� ,• a J� �_ i
Union . 01234009B
County Parcel Identification No.(PIN) NO V 2 2 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certi
(if well field,onebit/longissufficient) In'L .: .`^ . ?7
�(/ ,�
PGti��L r I 9/10/23 C}:e1 ;a
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that lire 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 ❑No 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 i21 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 I
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 300 (ft) 24a. For All Welis: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2(a3100') construction to the following: I
10.Static water level below top of casing: 30 (it) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
II.'Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In dddition 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: ry 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 27699-1636
13a.Yield(gpm) 8 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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013