GW1-2021-03042_Well Construction - GW1_20210622

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.wATER:zoNEs „ .
Well Contractor Name FROM I TO DESCRIPTION
2930-A 82 f- 92 fL COURSE GREY SAND
fL rt
NC Well Contractor Certification Number jg;OItTER CASING'forIDtilti eased 61fi'ORS,INER'if a._7rraDle_
J P ENTERPRISE
Company Name FROM To DIAMETER THICKNESS MATERIAL
+1 fa 82 ft 1.25 In SDR-21 PVC
356359 i6.INNER CASING OR TUBING eotherinal closed
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): f- f- in.
Water Supply Well: ;17:SCREEN �.
FROM TO DIAMETER "SLOT sI7.E" THICKNESS,.I MATERIAL
❑Agricultural ❑Municipal/Pubhc 82 fL 92 ft- 1.25 in• .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) ft. 82 ft- in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1g_GRO A = -777
❑hri ation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f- 20 fL 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft- BENTONITE
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
=19.SAND/GRAVED PACK;ifs livable .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft- 92 ft- #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed LOOP) ❑Tracer 20 DAZLING LOG attach add ititivat sheets if necessa
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,somroek qTe,grain size,etc.
0 I- 18 f- BROWN SAND
4.Date Well(s)Completed:4/28/21 Wen m#356359 18 fL 35 IL LIGHT GREY SAND
5a.Well Location: 35 fL 76 ft- LIGHT GREY SAND FINE/CLAY
JIMMY&LINDA POWERS 76 fL 94 ft- LIGHT GREY COURSE SAND
f.; a
Facility/Owner Name Facility ID#(if applicable) fL ft. �'( 'n r—
152 POWERS LN HERTFORD NC 27944 f. (-
Physical Address,City,and Zip ft. f- J�){\i ti . 2021
PERQUIMANS 72TREMARKs. :7T,----T
r,.: N
County Parcel Identification No.(PII I6"i�vili 3°,i^il I�r^Lt [1J 111
�
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22. •M lion'
36 11 06 N 76 21 30 W 4/27/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signs ed well ontractor Date
By si g this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing-well: DYes or ❑No 15A NCAC 02C.0100 or 15A NCAC 02C:a200 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 retard 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: 92 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd different(example-3(a)200'and 2Q1001
+7 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter. 6 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
mud rota Program,1636 MSC,Raleigh,NC 276 6'99-163
12.Well construction method: mud 24c.For Water Supply and Open-Loop 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 o ier 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13a.Yield(gpm)20 Method of test: P U M
O �
13b.Disinfection type: 73�O HTH Amount: 1.5 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018