GW1-2021-03086_Well Construction - GW1_20210622

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.,WATER-'ZONES
FROM TO DESCRIPTION
Well Contractor Name
30 145 ft• LIGHT GREY SAND 1A, 2
2930—A
NC Well Contractor Certification Number 15.'OUTER CASING tfor mold-cased.iWills OR LINER ifs"Liable ;__
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 33 ft 4 In SCH40 JPVC
Company Name
336309 16:INNER CASING OR.TUBING 'eathermal closed too "
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): fL fL In.
Water Supply 17.SCREEN
PP Y Well: FROM TO f DIAMETER ""SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33 ft- 43 ft 4 In" .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft 33 ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS.'GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO M, MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. fL BENTONITE
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEIVIENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft 43 ft #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control fL R
❑Geothermal(Closed Loop) ❑Trager 2010)RILLINGLOG attaehadditionslsheetsifnecess
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sotUroek type,zr2tn size,etc.
0 ft• 18 ft BROWN SAND
4.Date Well(s)Completed: 5/21/21 yet,TD#336309 18 rL 30 ft BROWN/LIGHT GREY SAND
5a.Weil Location: 30 ft- 43 fL LIGHT GREY SAND 1A, 2
JOSHUA ROWE ft. ft.
Facility/Owner Name Facility ID#(if applicable) FL ft.
120 BASNIGHT LN CAMDEN NC 27921 rL fL
Physical Address,City,and Zip ft ft n 3) 1
CAMDEN 028916009331330 21REMARK.S ' " `'
County Parcel Identification No.(PIN)
.: r CnSS;H`7 i111
u
�i vt ��Il�S�CI1C'•1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 C fiCatiou:
36 21 47 N 76 13 01 W / 5/21/2021
6.Ts(are)the well(s): Permanent or ❑Temporary Sil ature of Certified We Contractor Date
By rigning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis 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#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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:43 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdzerent(example-3(a3200'and 1 a@100)
10.Static water level below top of casing: +6 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: PUMP
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 2.0 OZ
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018