GW1-2021-06990_Well Construction - GW1_20210507

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltll :.14 WATERZONES t'. „' t„ .' r, ✓
Well Contractor Name FROM TO DESCIRMON
NCWC 4368-A 46 ft- 57 fl. mama cnr�
& fL
NC Well Contractor Certification Number =.•_.
34.:flUTERGASING �o"Ih±ease8;�s':ORStNt'sR a '._: > �;�,�,a.•�w>'
Maupin Well Drilling LLC FROM TO DIAMETER TmcravEss MATER)AL
fL tL in.
Company Name 16.INNER-CASING OR Ti DING tbumal--cl d400 ,
2.Well Construction Permit#:275217 FROM TO DtAME1T.B THICKNESS MATERIAL
Ilst a1/applicable mill conshuchon permits(Le,UIC.Comty.State.Variance.etc.) 1 fL 47 fl. 1 1/4 in. sir 40 w�
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER �sLOT SI78 TEUCNNM I MATERIAL
Agritulttmd E3Municipal/Public 47 fL 57 fL 1114 in. 0.010 sdr40 pve
Geothermal(Heating/Cooling Supply) Mikesidential Water Supply(single) R ft.
Industrial/Commercial 13Residential Water Supply(shared)
7)hTixafion FROM TO ' .MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft 48 ff. hdeplug gravity
Vie
ring Recovery f. fL
Well:
ft. &
Recharge Groundwater Remediation Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Test [)Stormwater Drainage 46 fL 57 ft• 1A gravity
ental Technology Subsidence Control M IL
mal(ClosedLoop) Tracer 20.DRiI , G'LOG attiemal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCR►MON color,Wrdn soi0roek o
.1 ft a fL gray day
4.Date Wen(s)Completed:30 April 21 Well iD# a & 14 fL fine yelaw sand
5a.Well Location: w ft. 20 ft Coarse yenow sand
Corey Speer 20 fl• 46 f►• gray day
Facility/Owner Name Facility ID#(if applicable) 46 ft. ft. gray sand coarse
176 Deer Run, Moyock 27958 fL fL
Physical Address,City,and Zip ft. fL
currituck 022D000000080000 :2LREMARKS ;, ,
Coty Parcel Identification No.(PIN) .N X,
mi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lmg is sufficient) 22.Certifiication•r..�---�^-•�•-
36.51359 N -76.11428 W �,a
_ 2 may 21
6.Is(are)the well(s)opermanent or 13Temporary Signatu eR - Date
By signing this form,I hereby certify that the well(s)was(were)constn7eted in accordance
7.Is this a repair to an existing wen: EgYes or,®No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the Copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 site details or well
construction,only I G W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 57 (ff-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:4, (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter:4 7/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
.Wen Construction method:
mudrotary above,also submit one copy of this form within 30 days of completion of well
(L
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh;NC 27699-1636
13a.Yleld(gpm)20 Method of test: pacer pump 24c.For Water SHnnly&lnieetion Wells in addition to sending the form to
the address(cs) above, also submit one copy off this form within 30 days of
13b.Disinfection type: HypOtChfite Amount: 9�? completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
RECEIVED
MAY X 7 2021
Information Processing Unit
DWR Section

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