GW1-2021-01646_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veld 14.WATER ZONES —_
Well Contractor Name FROM TO DESCRIPTION —
NCWC 4368-A 46 —
rL tL
NC Well Contractor Certification Number 15.OUTER CASING tw maltia'ased wells OR LINER if Cable
Maupin well drill LLC FROM TO DIAMETER THICKNESS MATERIAL,
Company Name 1 ft' 47 ft• 11/4 in. p,200 ,
339398 16.INNER CASING OR TUBING anal closed
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ti.e.UIC County,State,Variance,etc.) rt. n. in.
3.Well Use(check well use): ft. fL 1B
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaMblic 47 it- 57 fL 11/4 'n• .010 sch 40 pvc
Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) rL ft
Industrial/Commercial QResidential Water Supply(shared) I&GROUP _
hri tion FROM I TO MATERIAL EMPI.AC'EMENT METHOD&AMOUNT
Non-Water Supply Well: 1 fL 46 fr_ hdeplug gravity
Monitoring ORecovery ft. ft.
Injection Well: —
rL ft
DAquifff Recharge QGroundwater Remediation —
19.SAND/GRAVEL PACK Cifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM I To MATERIAL. EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage 47 ft- 57 ft- 1A gravity
Experimental Technology 13Subsidence Control R It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets tf aecessary)
Geothermal FROM TO DESCRIPTION(tabu aardnese,soiVrak etc
(Heating/Cooling Return) Other(explain under#21 Remarks) 1 rt. 4 r1
gray ctay
4.Date wells Completed: Well ID# a u 16 Apr 21 rL fL gray sand fine
5a.Well Location: 14 ft• 16 IL peat mosst brown
Stephen Hicks 16 ff• 20 ft• gray day
Facility/Owner Name Facility ID#(if applicable) 21 ft. a R. bee
528 Knotts Island rd Knotts Island 27950 22 ft- 46 ft gray sand _
k
Physical Address,City,and Zip 46 n- 57 ft- course gray sand In Una
currituck 0076000006500000 21.REMARKS
`�(p
County Parcel Identification No.(PM) 1r1 CJ V't
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) n-
36.52230 N -75.92545 �,
19 Apr 21
6.Ware)the well(s)OPermanent or Temporary Signature of Certified Well Contractor � Date
By signing this form.I hereby ceritfv that the xr/1(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the cop,ojthir 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 site details or well
construction,only I 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: 57 (ft-) 24a. For All Wells: Submit this form within 30 clays of completion of well
For multiple wells list all depths ifdii ferent(example-3(,200'and 2w100') construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 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
mudrotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,notary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13m.Yield(gpm) 20 Method of test' pacer pump 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: hyporchorite Amount: 3 Oz completion of well construction to the county health department of the county
where constructed.
Farm GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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