GW1--05099_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells , ,'
1.Well Contractor lnformatipn:
Huneycutt Dwight L.
14.WATER ZONES
FROM TO DESCRIPTION(
Well Contractor Name 178 i1 185 ft' 2 gpm
4070-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) -,
FROM TO _ DIAMETER' _THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 124 ft• 6 1/8 in• SDR-21 PVC
Company Name _ I6.INNER CASING OR TUBING(geothermal closed-loop) .
13318 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: l ft. 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 , MATERIAL
ft. ft. in.
❑Agricultural • DMunicipal/Public -
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring DRecovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology CI Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness.soitfroeklypc,grain sae,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 19 ft. Red Dirt
12/2/22 19 it 78 ft, Brown Dirt
4.Date Well(s)Completed: Well ID#
78 ft• 102 ft• Brown Rock
5a.Well Location: 102 ft. 405 ft• Blue Granite
Aimee Smith
ft. ft.
Facility/Owner Name Facility ID/I(if applicable)
Lynch Rd, Lincolnton 28092ft fL ft• Seams:135', 178'=2gpm,200',245',296'
Physical Address.City,and Zip 21:REMARKS S t.=tom, ''ir—7.1 1? '%-
Gaston 3631-21-7704 �I.L. L.t ki L.Li
County Parcel identification No.(PiN) h AUG
I I r 0 A ^023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: H
(if well field,one lat/lang is sufficient)
N W ,`., ri 1tv`Q/30G 12/19/22
Signature o Certified Well Contractor Date
6.Is(are)the well(s): 121Permanent or OTemporary By signing this form,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.Ts this a repair to an existing well: ❑Yes or EINo copy of this record has been provided/o the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1/2l remarks section or on the back of this firm. 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
submit one form. SUBMITTAL INSTUCTTONS
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 a/!depths ifdifferent(example-3@200'and 2(41100) 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
Rotary 24a above, 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,Underground 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. 1
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013