GW1-2023-02719_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: c­ -­ I
Dwight L. Huneycutt 14.,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name APR 0 119 It- 125 1" 75 gpm
4070-A Nei % ft.
NC Well Contractor Certification Number 15.OUTER CASING for ltigcd wells)OR LINER npqicable)
,FROM TO DIAMETER
r TRD ER MATERIAL
Derry's Well Drilling, Inc. 0 ft- 145 ft- 16 1/8 in1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(eeothermat closed-loop)
2.Well Construction Permit#: 2022-00002430 FROM ft TO ft. DIAMETER in. THICICiESS MATERIAL
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
OAgricultural OMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. It. UL
E31ndustriaUCommercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigqtion 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
[]Monitoring ORecovery 3 1 ft 20 ft- Bentonite Pumped
Injection Well: R. ft.
OAquifer Recharge CGroundwater Remediation 19.SAND/GRAVEL PACK(ifapp livable
)
FROM TO MATERIAL I EMPLACEMENT METHOD
0Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
[:]Aquifer Test ElStorinwater Drainage ft ft.
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ElTracer FROM I TO DESCRIPTION(color,hardness,sailirack type.grain size,etc.)
ClGeothennal(Heating/Cooling Return) DOther(explain under B21 Remarks) 0 ft 4 ft. Red Clay
4.Date Well(s)Completed: 12/13/22 4 ft- 13 ft Boulders
Well IDN
13 f" 145 B- Gray Granite
5a.Well Location: It. ft
Fox&Rabbit Timerlands, LLC fL ft
Facility/Owner Name Facility ID#(if applicable) ft ft Seams:W,59',77', 107',
Bells Grove Rd., Denton 27239 ft. ft. 119-125'=75gpm
Physical Address,City,and Zip 21.RENIARKS
Randolph 6684969842
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutis/seconds or decimal degrees: 22.Certification:
(ifwefl field,one Wong is sufficient)
_N W 1/10/23
Signature oiTerfificd Well Contractor C/ Date
6.Is(are)the wctl(s): [2]Permanent or OTemporary 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: DYes or [?]No copy of this record has been provided to the well owner.
If this is a repair,fill our knmvn well construction information and explain the nature of the
repair wider 921 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
1 1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths itdifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 10 (ft) Division of Water Resources,Information Processing Unit,
IfiPater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
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,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) 75 Method of test: Air 24c.For Water Supply&Infection 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 GW-I N6rffi Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013