GW1--05073_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES. i
FROM TO , DESCRIPTION
Well Contractor Name `a L C 4..,tz a'o I- 168 ft 175 ft 25 gpm
2465-A ( ft
NC Well Contractor Certification Number A U.G 0 �! 2 D 23 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lit able)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. In►euL;a£)en 2rn75 e: o ft. 62 ft- 6 1/8 in- SDR-21 PVC
Company Name DiliUSOG ('tom 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-00002427 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in. •
List all applicable well permits(i.e.County,State,Variance,Ir jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. in
•❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it tt in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 ft• Bentonite Pumped
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) ,
El Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 50 ft• Red Dirt&Boulders
4.Date Well(s)Completed: 8/5/22 Well ID# 50 ft 245 ft Blue Rock
ft. ft.
5a.Well Location: ft, ft.
Fox&Rabbit Timberlands,LLC ft. ft.
Facility/Owner Name Facility Ill#(if applicable)
Bells Grove Rd, Denton 27239 ft ft. Seams:77-105', 115', 135', 140',
ft ft. , 149', 168'=25gpm, 180'
Physical Address,City,and Zip
21.REMARKS
Randolph 6684969842
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 644, � i/GG _ 8/25/22
Si of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RINo copy of this record has been provided to the sve!!owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks,section or on the back of this fornx 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 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 INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2®100') construction to the following:
10.Static water level below top of casing: 38 (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
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) 25 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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