GW1-2021-00757_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD
This form eall be used 1u1 sitrale or nudtiple\\elh
I.well Contractor Information:
Dwight L. Huneycutt F WATER ZONES
ROl1 'ffl 1)ES('RII'TI(1A
\\ell C out:r for\ante 250 f'' 255 f`' 50 gpm
4070-A ft. ft.
\C'\\'<•II(ontraetot Cedilicatiun Xumber 15.O['TER CASING(for multi-cased bells OR LiNk:R(if a Iicable)
FROM TO WAMEIER T 'IHIC,v1E5S \fA'Ik:R1AL
Derry's Well Drilling, Inc- 0 f' 45 f` 6 1/8 i1'- SDR-21 PVC
(,„lit,.,,,\.\mnc 16.INNER('ASING OR TUBING(geothermal closed-loop)
2020-00002722 FROM 1-0 DIANIETEN THICKNESS MAIERI%L
2.R'ell Consfnu•lion Permit k: GL ft. ft. in.
L,.r ali npph<able rwillvonn,p.e.(oaut Vulr. I anan"'.Mle,1111P.e/<.:
3.R"ell Use(check Hell use): 17.SCREEN
Water Supply Well: FRONT TO DLUIF.TER SLOTSIZE I rnICK\ESS %1A1ERlAI,
ft. ft. in.
FAerlcultural LMunlcipal%Public
LOcilthermal(Heating[Coolutg Supple) LResidential b1'atei Suppl)(single) ft, ft. in.
ClndusulalrConunerccd GResidential Water Supl)I% (shared) 13.GROUT
FROM 10 MA ERIAL EMPLACEAI E\I'\I E HIM)S A\IOL\7
ChTi alto❑ ft. 1'r.
0 3 Bent.Chips Gravity
Non-Water Supply Well:
LMonitoring GRea)\"cn 3 ft- 20 ft- Bentonite Pumped
Injection%%ell: ft. fr.
LAquder Recharge LGroundwater Rcunediatoll 19.SAND/GRAVEL PACT:(if applicable)
E\IPl_\CEME�I'METHOU
CAquifer Storage and Rcco\en GSalmin Barrier FROM 10 MATERIAL.ft. I tf.
CAquilei Test G lr Stornmat Drainage
` ft. ft.
LFvperimental Technology LSubsidence Control
21).DRILLIr\G LOG fattach additional sheels if necessan I
[(ienlherinal(Crlosed I-(lop) F.T racer FROM '10 DES('RIP'Il()\(color.hardue>e.miVrnckq e.2,'oio,ize.etch
f-Geotherrnal(Hcatn�%Cooluig Return) L(hher(e\plah)under�31 Remarks) 0 ft. 18 ft. Red Dirt
8/4/21 18 ft- 265 f`• Blue Granite
�.Date 11 OWN)Completed: Well TD"
fr, ft.
5a.\\ell Location: ft. ft.
Jim Tipton /Alyce Tipton
Facility nv%natAanle Fac,bn ID=(ifapplicable)
f` Seams:65', 123', 13T, 146 232',r 250'=50%g '
6851 Brantley Gordon Rd., Denton 27239 ft. ft• DEC 8 202i
I'fn-stcal Add,-e—t it,.and 7\p
21.REMARKS
Randolph 6688964405
<ounq' Parcel Idemilication No 1pl\V) - "-
Sh.Latitude and Longitude in degreeslnninutes(seconds or decimal degrees: 22.Certification:
(it well field one lalilmle is,uflicientr
\1 8/26/21
Signature n C edified\1"ell C'nnI actor Date
6.Is(are)the eell(s): FLLPel'nlarlent or :14'emporar)
Nc dru Inrnr, !hrre•hC rrrn)v rhui rhr nxdl++J utu(n crc/unvemvru•d to,dt rurkvru•
uvdr/�.-f 1(_q[ tQC 0l00 ur Li"_!\Y A: 10 1( .020l)fi id! it
7.Is this a repair to an existing well: J1es or JNb opt nl this ret ord bu%been pror+drd ro the it ell miner.
Iftha i,a rc7+<+n',till our known wel!co-tr•ur[tu 7 mtlnrmatrun aryl egda:n then alf e nt the
re/trir tinder ?l remarks minor or on the buck of du,:t.rrmr. 23.Site diagram or additional well details:
You ntay use the back of this page to pro%ide additional \%ell site details of well
S.Nunlher of%cells constructed: 1 construcnon details )'Oil IlIa\ also attach additional pages itnecessar\
/-e>r nmdtiole roil'.nM or non-twier suppl, ,relit 2\'!.1'a illy lhr.enntc runstruc•fhm.rna<:ai - -
vrhwlt oue twill, SUBMITTAL INSTI'C:TION"S
9.Total%sell deptil belo%%land surface: 265 (ft.) 24a. For All \%'ells: Submit this loran \Chin 30 daNs of completion of\)ell
"or multiple t,ell,/esr u!l deft).+o d(/lerem(te,zumple-3",F 200'and_rri lu(!I constnlction to the following
if).Static eater le%el helot% lop of casing: 13 (ft.) Di%ision of Water Resources.Information Processing Knit.
!/enter lrcrl r+uhorc c<r...1,.u•r 1617 Mail Scr%ice Center.Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241). Por Iniection Wells ONLY: In addition to sending the brill to the address In
Rotary 24aabu\e. olsn suhmrt a alp% of this tollil nithlll _10 da\s tit completion of\\ell
12.\\ell construction method: construct loll to the Iollo%)ing
rt e aupa,.,atan.cattle.dnect push.etc i
Di%ision of%%titer Resources,li nder,round Injection Control Program,
FOR 11':1TI:K S1`PPL1 WELLS ONLY: 1636 Mail Sen ice Center.Raleigh.NC 2 7699-1636
13a.Yield(gran) Method of test:
50 Air 24c. For N ater Supple s Injection i11 ells:
Also submit one cop) tit this form \\Rhin 30 da\sofcompleloll oh
13h.Disinfection tY pe: Granular Amount: 1/2 lb. \\ell construction to the count\ health depaon)cnt of the count\ \there
constructed
I ohm OR--I `C,nth Carolma Deprnunent of Elm ii imenl and\anual Re,omces Dty,aua,nt\\ate,Resources Ite\-,sed August 2013
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