GW1-2021-03062_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Vettri ;14 WATERZONES rF,, .,.. k. ,
Well Contractor Name FROM TO I DESCRU!t'ION
NCWC 4368 A 71 R 76 R
R R
NC Well Contrulor Certification Numbs
7S.'017iER'CASING taar.�oUi=eartd rrir_lls OR LRVER`d`
Maupin Well Drilling FROM TO D1AME'IFdt T/tICKNF.SS MATERIAL
1 fL 71 R 11114 �' sch40! pvc
Company Name 76::INNERCASING'.OR'i'UBiNG: ' elosedaoo '..., -� . . �.:.'�-
L Well Construction Permit#:326358 FROM I TO DI4M]L1= I TRICKNM I MATER AL
Llrt aft applicable uWl consbuction permits(le.LUC,County,State,Variance,etc) It. It.
3.Well Use(check well use): fL IL 1°
Water Supply Well: 17 SCREEN
FROM TO DIAMEM SLOT S12Z I.;.TMCNNM MATmttAL
Agricultural 13Municipal/Public 71 fL 76 R 1114 'a 0.010 sch4o pve
Geothermal(Heating/Cooling Supply) }Residential Water Supply(single) it. ft. ;n
industrial/Commercial Residential Water Supply(shared) :1t1 GR01JT
irri ion FROM TO MATP1mAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welb I fL 70 R holephig gravity
Monitoring Recovery ft. fL d
Injection Well: tL R
Aquifer Recharge Groundwater Remediation
J9:'6z13Vt)/G12AV$3:'PACK d• >��, .. �,<: ..�?,f_43., r;
quife<Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPIACEMENr METHOD
Aquifer Test [3.S'tor'mwater Drainage 70 fL 76 fL DS1 1A gravity
Experimental Technology Subsidence Control R R
Geothermal(ClosedLoop) 13Trecer 20.DRQLINGIOG:ittubadditibris7sircets3tiea�
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIMON eobr,tuada soW- is eh.
1 fL 6 4L clay
4.Date Well(s)Completed:10 June 21 Well EN 6_ ft. 22 R
yellow faaxn card
5a.Well Location: a It. 26 It. sties and day
Ronald Dowell 26 ft. 32 ft. gray sand
Fac7ity/Owner Name Facility 1D#(ifapplicable) 32 ft. ro f. gray day
J4 C)I Middle Gibbs Rd.Knotts Island 27950 70 ft' 71 ft loss 1
Physical Address,City,and zip 71 fL 76 it gray sand cesE ing Unit
Currituck 0029000023A0000 z1rRFattARxs ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVbng is sufficient) 22.Certification:
36.53526 N -7609211 N
i 11 June
6.Is(are)the well(s)OPermanent or Temporary Sr ru,ea grew k ammcror �laete
By signing this form,1 hereby cerrifv that the wen(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,fill out known well consirwion information and explain the nature of the copy of this record has been provided to the wit owner.
repair under#11 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 1 GW-1 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: 76' (ft) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths 1fdiI ferent(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing:5. (ft) Division of Water Resources,
lfwater level is above caring,use..+^ Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4 7/8 (in.) 24b.For Injection Wells: In addition to sending'the form to the address in 24a
12.Well construction method:
Mudrotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test:pacer pump 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy ofi this form within 30 days of
13b.Disinfection type: Hypochrite Amount: 3Oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envirmrmental Quality-Division of Water Resources Revised 2-22-2016

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