GW1-2021-05352_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Itdormadw.
Daniel C.Veltri
wellconuwtmName FROM TO �I DESCRIPTION
NCWC 4368-A 21 It. 28 ft.
OCj 1 3 2021 , It
NC Well Contractor Certification Number I&Ot7TPJt,G`ASING, mutt iiseil OR LMR d
Maupin Well Drilling LLC pCo�E:5S1I19 lltllt FROM To DUMemt TAICIOVESs MwTFanv
Company Name 1 �� DL�� CCU +1 it- 21 ft- 2 to. SUt�OI live
361140 t6 mvexcAsnvcoRTOIllilrc
2.Well Construction Permit# FROM TO DIAMETER I TMCX74M I MATERIAL
List all applicable ue1/conshwetion permits r e.WC,County,State,Variance,etc.) It. fL in-
3.Well Use(check well use): ft ft in.
Water Supply Weil: 17:SCREEN -
FROM I To I DIAMEIBR sI.OTSI2E I 7MCX MSS I MATERIAL
Agricultural ®Municipal/Public 21 ft• 28 fL 2' 1° 0.010 srh40 pvc
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) R iL iv
Industrial/Commercial DResidential Water Supply(shared)
l&GROUT
irrigation FROM TO MATERIAL EMPI ACEafENIT METHOD&AMOUNT
— -Non-Water Supply-Well: -- I It, 20 fL weptog gmvtty ---
Monitoring Recovery ft. It.
Injection Well: ft_ IL
Aquifer Recharge DGroundwater Remediation ]9.SATII)1GRAYEI'PACK.eta`'' ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EAH%ACEMIM METHOD
Aquifer Test 13Stormwater Drainage 21 IL 28 ft- 1A gravel pads -gravity
Experimental Technology OSubsidence Control tt ft
Geothermal(Closed Loop) [3Tracer d0.DPJLLI TGLOG o t eh addidonalsheeb 9t neccase
Geothermal(Heating/Conlin Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,aura sotVrvrk ft$12e,etc
/ it. 5 IL topsos
4.Date Well(s)Completed:15 Sept 21 Well ID# 5 It. 10 % yellow sand
5a.Well Location: 10 ft 14 f! gray day
Frederick Lane 14 it. 28 & gray sand
Facility/GwnerName Facility[D#(ifapplicable) ft. ft.
107 church Lane,Knotts Island.27950 h. ft.
Physical Address,City,and Zip It. fL
Cuirituck 077C00000070000 n.'REINARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesh®Dtes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 27-Certifica' -
36.51110 N -75.92207
16 sept 21
6 Ware)tare we0(s)j3Permanent or OTeniporary of a Co Date
By signing this form,I hereby cenVv that the well(s)xus(wee)evnsnveted in accordance
7.Is this a repair to an existing well: ®Yes or ®No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Consnvcaan Standards and that a
lfthis is a repair,fill our blown well cmistrvction information and explain the nature of the copy ofthis regard has been provided to the well omwer.
repair under#21 remark sermon or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Imp 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.
driUc& SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28 (fL) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdiffowit(example-3Q200'and 2@1001 construction to the following:
la Static water level below to of 5 p casing: (R.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
I Borehole diameter. 5 7/8 (1) 24b.For Injeetion Wells: In addition to sending the form to the address in 24a
12. Mud Rotary above,also submit one copy of this form within 30 days of completion of well
Well construction method: construction to the following:
(lee-e.auger,rotary,cable,diner push,
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail 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 addresses) above, also submit one copy of,this form.within 30 days of
13b.Disinfection type: Hyoctorite Aunt. 4 oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2- 16
CEIVED
SEP 2 4 2021
NC DEQIDWR
Central 0tfice

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