HomeMy WebLinkAboutGW1-2021-03409_Well Construction - GW1_20210607 -
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only.
1.weII CoDtreetor latortanttioa:
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WtOCoatractarName FROM I TO DESCRIPTION
i 46 ft 56 %
NCWC 436$-A X r� 2Q�,
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Maupin Well Drilling LLC C� FROM m DiAM2.0
THICKNESS MATERIAL
A t �- 46 n' s IA - sd+so arc
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2.WeR Construction Pomsit#: FROM I TO DtAMET R iffiC< S i MATERIAL
LW all gWN-ble—IF owcstructionpermits(4 ey.e.WCCoon ,StateParun-g,etc) tt ft is
3.Well Use(check well use): n, fL (n
wa sap*we& iTtSt NEENs "... t..
FROM1 I TO 3..•.:..I WMIKTER ` s'LOTSIZE` �TllICMt-Ins I MATERIAL
Agticnittaal DMunicipaUPublic 46 R. 56 t tt4 la 0.010 scn 4tI pvc
_ Owthennal(HestingiCooling Supply) [@Residential Water Supply(single) it n. IM
bulustrialicommercial 13Residentiai Water Supply(shared)
_ ..FROM TO MATERIAL I�LA�ffiy'rMETHODAAWIDUW,
Non-Water Supply well: 1 fL 45 IL hdepbtg gmvky
Monitoring [.Recovery, ft. ri
IDjeetlDn Weil:
R IL
Recharge OGroundwater Remedliation
>4A'SATID/GRAVELFT►CK" t, s
Aquifer Storage and Recovery 0salinity Barrier FROM To MATER AL EMPLACEMEIrrME1IIOD
Test OStormwater Drainage 46 ft. W ft- to I;nmvfty
ToclmakW OSubsidence Control R &
Geothermal(Closed Loop) Oi'raca 2A'tDRILI 2NG 1 OG;iittAeii:additiaoat r7
Geotheaatat(Heatsa fin Return Other lainunder#21Remadts FROM TO DFSCRmron(cabrGudaeamN,scr s etc
t ft- to ft. "Clay
4.Dab WeWz)Combed:7 May 21 well w# 'to ft, t6 it V,ySaml
3a.Wen Location- to r' 22 D' lvayday.
Carl Talley 22 ft 26 ft graysand
r9crTuyt Nmmc F-IftyM(itupplicable) 26 fL a M nay
210 Elrod rd Moyock 27958 44 n. 56 ft-
Physical Aa&-%City,and rap A. fL
Cllrrituck 00310000005B0000 `;21rR1SNiARtGs >
ow"y Pascal Identi6mUoallo.tPtN)
5b.Latitude and laogHade in degrms/miaates/seeonds or dedfiW degrees:
(if wall faebl,—ballo E is si>lliciano 22.Certification:
ter,,._....
36.488809 N -76.o8341 W_� 12 May 21
6.1gam)the wells} Permanent or OTesuporary Si Dane
1 v signing this form.I hereby certify that the twiffis)teas(were)commaxed In accordance
7.Is this a repair to an existing well: [3Yes or EINo Wth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known»ell construction information and explain the nature of the copy ofthfs hoard has been provided to the well on,mer.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geeprobc/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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 9UBMl7TAL R[a UCTIONS
9 Total well depth below land s"face: 00 24a.For All Wells: Submit this form within 30 days of completion of well
For muldplewelk list alidepthsifdijjereat(example-3a@200'and 2@1M construction to the following
10.Static water level below top of easing:2' 0* Division of Water
!fbaler'Anrlisabosecashigµre^¢^ R Center,
InformationPreee;ssiagUnit,
162T Mail Service Center,Raleigh,NC 27694-1627
il.Borehole diameter 4 7/$ (in) 24b.For Infection Welts: In addition to sending the form to the address in 24a
Mudrotary above,also submit one copy of this fors within 30 days of completion of wall
f well construction cable,
method:push, construction to the following:
{re. notary,table,dnecr push,Gc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27692-1636
13a.Ysdd(Bp®)20 gpm Method of test pacer Pump 24c.For Water Sumly&Infection Wddlfi in addition to ceding the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfed'mn typ. Hypocfiorit0 Amontit: 3 fJz corupte Lion of Weil construction to the county health department of the county
where constructed..
Ftrrsn GSV I North Carolina Department of Environmental Quality-Division of Water Rcmmces Rmived 2-22 2016