GW1-2021-00375_Well Construction - GW1_20211228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 1CY, ERZONES,t . . .
Well Contractor Name FROM TO I DESCRIPTION
2930-A 21 fL 26 ft- LIGHT BROWN SAND
ft. fL
NC Well Contractor Certification Number '152OUTER'CASING for multi case6 wells OR LINER'if's llicable
J P ENTERPRISE FROM To °'"METER TM
MATERAAI
+1 ft. 21 ft 1.25 in. SDR21 JPVC
Company Name
366179 16TNNER'CASING OR TUBING eothermalslosea-loop)
_
L Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in
3.Well Use(check well use): ft. f, in.
Water Supply Well: 1F�R SNCREENTO DIAMETER.!...,SLOT SIZE THICIINESS MATERIAL
❑Agricultural ❑Municipal/Pubhc 21 fL 26 ft- 1.25 i° .010 SCH40 PVC
❑Geothermal(Heating/Coohng Supply) InResidential Water Supply(single) ft- 21 fr.
❑Industrial/Commercial ❑Residential Water Supply(shared) W GROUT
01tri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 fL 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. fL BENTONITE
Injection Well: fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK a licabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 n. 26 ft- #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer '20:DRELLING IAG attach additional sheets if necessa
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hudoess,soiurotk type,gain size,etc.
0 ft• 26 n LIGHT BROWN SAND
4.Date Well(s)Completed: 11/19/2021 Well ID#366179 fL rL
Pft it
5a.Well Location: IL ft.
PEGGY TILLETT ft.
Facility/Owner Name Facility ID#(if applicable) fL ft. a 7021
6869 CARATOKE HWY GRANDY NC 27939 ft. fL
Physical Address,City,and Zip ft. M
CURRITUCK 0108000000310000 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 Certificetioy
361257 N 75 52 00 W C /) 11/19/2021
6.Is(are)the we►l(s): OPermanent or ❑Temporary SialatureofCe ed Well Contractor Date
By igning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Yes or ❑No 15A NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out brawn well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 26 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.well construction method: MUD ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed P
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gum)20 Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% hth Amount: 1.5 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018