GW1--06757_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: - •
•
1.Well Contractor Information:
Gary C. Honeycutt 14.WATERZONES I
FROM TO DESCRIPTION Well Contractor Name _
400 ft. 7 ao ft I
2230-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if np 'feeble) •
Locust Pump S:Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 1 ft. a ft. 4 At in. Spy PVC.
�� - 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well coastructian permits(i.e.U1C,County,State,Variance,etc.) ft. ft. i
r.
3.Well Use(check well use): ft. ft. in.
:17,SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE TIIICKNESs MATERIAL,
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply)' esidcntial Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •
❑irrigation ❑Wells>100,000GPD FROM TO MATEIUAC EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. so ft. yo%r/o /o 46034.5
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifcr Recharge ❑Groundwater Remediatiou
19.SAND/GRAVEL PACK or applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AquifcrTest ❑StormwaterDrainage ft. ft. //
❑ExperimcntalTccltimology ❑SitbsidcticeConlrol ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional Sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soll/rock type,train size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © n ?O ft. �D/;�
4.Date Well(s)Completed: i -262-2-Well ID# 3 G ft. 40 ft. .
5a.Well Location:( 40 ft. Cj Er R. 6r. p A_f ezcK.
13. CooK ft. ( ft�Q ft. &iV 04
Facility/Owner Nome Facility ILO(if applicable) • ft. ft. ''`-.T"-"- r r.--=:;8 .ao 3ds Groueck Rd JA haw..3 e, ft.
----
Physical Address,City,and Zip ft. ft. 0CI J ZQ 9
, ee N 1 21.REMARKS L LJ
l c 1'O t+- 11-1 f iG`%!:i1 r)r7,:-. 7•:::9 ly!:
County Parcel Identification No,(PiN) '_• •;..�::,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lnt/long is sufficient) 22.Certification: •
3$° 5 .34 N $ao 4L.6dL w Gary C. Honeycutt q '2./-2o?
6.Is(are)the well(s): Q1Pcrmanent or OTemporary
Signature of Certified Well ContractorDate
By signing this form,I hereby certify that the iiel1(s)was(were)constructed is accordance math
7.Is this a repair to an existing well: ❑Yes o1• no 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction Information and explain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this foran.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to,provide additional well construction info
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: age 24.SUBMITTALINSTRUCTIONS
I
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completionper the following:
For multiple wells list all depths ifdjQerent(example-3 a,?00'and?a 100') y p
• kV 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (IL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1/'water kvel is above casing,use"+"II
11.Borehole diameter: p (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
'C� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: '1`erk-tairY 24c.For Water Supply and Open-Lo�p Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpnl)
2 Method of test: I a Permit Program,1611 MSC,Raleigh,NC 27699-1611
`` y
13b.Disinfection typc�aD` Amount: J CIS 77/e
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018