GW1-2021-03411_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-11 For Internal use only:
L Well Contractor information: j
S®5d'
DanlelC.Veltri �
Wd1CantractorNause �Owa FROM TO DESCRn!ION
NCWC 4368 A J�N X 7 Ll 6D ft 70 fL
NC Weti Conu.ctar cuuTiralitra xtttabQ
pr�� sirl�Unit ft ft
Ma in Well i3n7fin LLC Ir1#ter ''�tlorl •asvvrER:casrNG "oi�a<aiea:" oR:lJn R .
9 tIC Jj Cef,'t1011 F.- T DIAMETER 111111 O m MATFymAL
Co paayName 1 ft 6o ft t 1l4 side-ao a,e
3588U81 -Y6INNER'C'ASINGt]R=TOBiNG- ._. ". _
7-Wen boa Permit#: FROM To IAM6IER T�CrQ�SS MATERIALLitt all applicable nvil oorstraeOoa permits Cce WC Caun+la Star&Parwaee,etc) ft ftfrs
to
3.Well Use(cheek well use): ft IL 1.
watce S ly well: .17.`,SCREE3
FROM I To DIAAl6Q�7R f S7p{y�•:,- T MA.M...
OMunicipayptimic 60 ft 70 ft t 1ta =0 Ita1140 on
mal
Geothermal(IieatinglCoolmg Supply) Residential Water Supply(single) g ft
i�ushial/Commevaial bResidentiai Water Supply(shared) Yg Gliftlition ttOUT
r
FROM TO`.,..: ,MATERIAL-:•, ENNACE E TT'METHOD&AMOUNT
Non-Water Supply WeO: 1 ft 59 ft t 9 �
omtn W Rexovery ft ft
Injection Well:
ft ft
R� E)GroundwaterR�lation
39:SANDI6RAVFd-PAt�C _ <.
gviferStorageandRceovay 0SalinityBarrier tROM TO MATERIAL sttwt icsii�rirMETHOD
rrTest [3StormwaWDrainage 60 & 70 fL to gam,
EVairutntal Tedmoitogy Subsidence Comm! ft ft
Geotheamal(Closed loop) 13Tracer 20.'<DRtLLIN(sI.OG Bitietiadd1130n81`stiseb"tf
_Geotbennal{Htatin Rehm Other(explain tmdertt2l Remarks) FROM To Dtncarvrtoxemler adYroek ells
1 (L 4 & "day
4.Date Well(s)Completed:25 May 21 Well ID# 4 ft. 14 ft
galr$a<w
Sit.Wen imeadoD: ,. % to f1. gray day
Kay Steeley 18 ft 25 ft. gray Said
FasddyiOamaName Facility M#(fapplirmblc) 26 & x ft- Clay am
130 Robert Walker Rd, Moyock 27958 36 ft 53 ft wwd-y
Physical Address,City,taut Zap 53 % 70 f L yellow and gray sand muted
Currituck 0040OW0310000 2 REAfARxs--.
County Fame]Ideotifitation No.(PIN)
5b.Latitude and longitnde in degreeshmmrtesfseronds or decimal degrees:
Ctfwa field,one Iatilam is saf5cied) 22.Certification:
36A7%9 N -76.04654 .-w
�� 26 May 21
6.15(are)theweil(s)J0Permsnent or 131remporary Sitdabue edlCo
By siV-W this jorm,I bereby coo thou she mA(s)rias(were)eat—%a Fa aono�aoe
7.Is this a repair to an edsting well: QYes or J@No with ISd NCAC 02C.01W or 15A NGfC 02C.0200 X Cangnartion Shm dords and char a
l&W is a mpsw,jet!ota kwvm well construction information aml etylain the nature ojthe copy ojthir record has been provided to the xdl caner.
repair under#21 remarks realm;or an the back ofthie form. 23.Site diagram or additional well details:
&For Ceoprobe(DPT or Closed-Loop;Geothermal Wells having the same You may use the bade of this page.to provide additional well site details or well
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells baron details. You may also attach additional pages ifne:oessary.
drilled:
SUBNIITTAL INSTRUCTIONS
9-Total well depth bedew land surface 70 (ft) 24a.For All WeFts Submit this farm within 30 days of completion of well Forma fewe�/istafldrpda jQi$erart(e r-ple-3Q200'aed2@1W) construction to the fotlowing
10.Static water level below top of casing:12 ft
( ) Division of Water Resources,Information Processing Unit,
/jtmterletel is above earhrg:use 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter 7/8 (in) Mb.For Injection Welts: hi addition to sending the form to the address in 24a
12-Wen construction method: Mudrotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(t.e.auger,Rotary,mb]R dam push,etc.) &
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MA Service Center,Raleigh,NC 276994636
f3a Yieh1(8p®) 20 Method of test pacer pub 24c For Water Saoniv&Injection W� In addition to sending the form to
the address(cs) above,also submit one copy 'of this form within 30 days of
lab Disinfection type: FiypoChrite Amount: 3 oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Departm at of Environmental Quality-Division of Water Resources Revised 2 22 2016

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