GW1-2022-01244_Well Construction - GW1_20220113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14:WATERZONES FROM TO DESCRIPTION
-
Well Contractor Name
2930—A 24 fL 29 fL LIGHT GREY BSAND/ SHELL
st ft
NC Well Contractor Certification Number 15OUTER.CASING for muMt cased wells OR LDVER'if a``"Leable
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL.
+1 fL 24 ft 2 in- SDR21 PVC
Company Name -
#366636 :16ANNER°CAS1hTG'OR TUBING euiherrnal erased lon
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: °17.'SCREEN ,k,
FROM TO DIAMETER SLOT SIZE THICKNESS !MATERIAL 4
❑Agricultural ❑Municipal/Public 24 ft. 29 fL 2 in. .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) In Residential Water Supply(single) fL 24 ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT. .
Obligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fQ 20 ft• 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft- BENTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`39:SAND/GRAVEL PACK Ta lie'ible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERAAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 fL 29 fL MAND IGRAVITY
❑Experimental Technology ❑Subsidence Control ft• fL
❑Geothermal(Closed Loop) ❑Tracer 10..DRIIZINGIUGi atfachFadditionalsheetsifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc,
0 fL 13 "L BROWN SAND
4.Date Well(s)Completed: 12/10/2022 Rteu Em 366636 13 fL 20 LIGHT BROWN/GREY SAND
5a.Well Location: 20 fl- 29 ft LIGHT GREY/SHELL SAND
MICHAEL FOLDS IL f` �--�
Facility/Owner Name Facility ID#(if applicable) fL ft. P"7—diZ t:.1 i e N,t rKa
5709 CARATOKE HWY POPLAR BRANCH NC 27965 fL fL
Physical Address,City,and Zip ft. fL AN i 3 �O 7
CURRITUCK 0084000004E000 3f:RiElrlARxs.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
36 16 55 N 75 54 53 W 1/6/2022
6.Is(are)the well(s): dPermanent or ❑Temporary S' of Certifi Well Contractor Date
By ing this form,I hereby certify that the well(s)was(were)constructed in accordance with -
7.Is this a repair to an existing well: MYes or ❑No 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out(mown 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 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 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:29 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
+ 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:6 (in,)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing'over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test: P U M P
Permit Program,1611 MSC,Raleigh,NC 27699-1611
O OZ
13b.Disinfection type.73/o HTH Amount: 1.5
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018