GW1-2022-10015_Well Construction - GW1_20221107

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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:
Dwight L. Huneycutt 14.WATER ZONES
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7 Y E"� "� °'"' FROM TO DESCRIPTION I
Well Contractor Name I L 255 ft 260 ft I 1 gpm
4070-A NOV 0 1 2022 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells'OR LINER if a licable
Derry's Well Drilling, Inc. Ir1wf an Proc .fg UrA FROM ft TO ft.
DL111tETER„r TIQCIavEss AIATERL'T
ry g Jig, 0 46 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TURINGIpeothertnaI closed-loop)
20r�r�-00000708 FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit t1. L G 22 8 ft. fr. in
List all applicable well permits(i.e.Count,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fr. is
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 rr. 3 ft Bent.Chips, Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft. 20 ft Bentonite;' Pumped
Injection Well: ft. ft.
ElAquiter Recharge ❑Groundw'ater Remediation 19.SAND/GRAVEL PACK ifa Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I, I ENIPIACENIENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control fr. ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal{Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness,seutrocktype,gain sae.etc.)
❑Geothermal(TTeating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ' ft 7 ft i• Red Dirt
5/3/22 7 ft. 24 ft- Brown Dirt
4.Date Well(s)Completed: Well iD#
24 fr• 38 ft. Brown Rock
Sa.Well Location: 38 ft. 500. fr• Slate
Ken McDowell ft. ft
Facility/Owner Name Facility iDA(ifapplicable) '
ft.
5505 Lakeway Rd, Denton 27239 ft Seams: 75',79',88',96', 112', 190',
ft. fr. ;255'=1g,297',390%394'
Physical Address,City.and Zip 21.REA1APkS
Randolph 7701307904
County Parcel identification No.(PiN) I
5b.Latitude and Longitude in degrees/minutWseconds or decimal degrees: 22.Certification:
(ifwell field,one hit/long is sufficient)
N W D � 6m22
Signature of.ert�itied Well Con tractor Date
6.Is(are)the vt'ell(s): OPermaneut or ❑Temporary Ry signing this form. 1 hereby certify dun die wel/ft)teas(were)constructed in acc•ordtnic•e
frith 15A NC AC 02C.0100 or I5A NCAC.'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l]No cony(#'this recard has been prnrided to the ii ell owner.
/j•this is a repair,Jill out known ivell construction injbrmation and explain the nature of dhe
repair under a21 remarAs section or on the back ofdNs Jorm. 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 ma_y also attach additional pages if necessary.
Por multiple hjeelion or non-watersupply wells ONLY with the same conoruedan,you can ;
submit oneJimm. SITBMITTAL INSTUCTiONS
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For inulifple welds list all depths ifdtgerent(example-3@200'and 1@100') construction to the following:
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10.Static water level below top of casing: 78 (ff.) Division of Water Resources;information Processing Unit,
Ifu•ater level is abore casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
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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
12.Well construction method. Rotary construction to the following:
(i.e.auger,rotary,cable,diiect pwsh,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,,Raleigh,NC 27699-1636
1 Air 24c.For Water Supply&Injection Wells
13a.]'fell(gpm) Method of test: :
Also submit one copy of this form ,,4irt 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 OW-I North Carolina Department ofEnvironmenl and Natural Resources—Division of Water Reso Revised August
urces