GW1-2021-02186_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information: G �
JOHN PAUL SIMPSON i
14'WATER'ZONES r '
Well Contractor Name FROM TO DESCRIPTION
2930-A 1UL �' Uni153 fL 63 fL LIGHT GREY SAND COURSE
processing ft. ft.
NC Well Contractor Certification Number n
J P ENTERPRISE r;,a��'�5g�r'on 15;OUTER�ASING fotmulti-casedwell§.ORL7INER ifa licable
D FROM TO DIAMETER THICKNESS MATERIAL
+1 fL 53 fL 1.25 i° SDR-21 JPVC
Company Name t�
356359 16.INNER CASING OR TUBING eothermal closed4otiol
2.Well Construction Permit#: FROM TO DIAMETER 1 1 THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft I ft. in
Water SuPP1Y Well: 17.:SCREEN':
FROM TO DIAMETER SLOT SUE, THICKNM MATERIAL.
❑Agricultural ❑Municipal/Public 53 It 63 1.25 is .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) IhResidential Water Supply(single) fL 53 ft- in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT, `i:,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ? EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft 3/8 holeplug GHRAVITY
❑Monitoring ❑Recovery ft. fL 13ENTONITE
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL IIKPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 fL 63 ft #2 SAND ', GRAVITY
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necrossef
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiVrwk type,grains etc
0 ft- 14 rL BROWN SAND
4.Date Well(s)Completed: 6/1/21 Well 11)#357359 14 ft- 48 n- CLAY/FINE SAND
5a.Well Location: 48 fL 63 ft. COURSE LIGHT GREY SAND
TIMMOTHY BOYD ft. n.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1104 NORTHSIDE RD ELIZABETH CITY NC % ft.
Physical Address,City,and Zip fL ft.
PASQUOTANK 1.-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 e 'fieatio
36 21 36 N 76 16 14 W 6/10/2021
6.Is(are)the well(s): ❑Permanent or ❑Temporary Si ture of Certified welt ontractor Date
By igning this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!Drown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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: 63 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdijjerent(example-3@200'and 2@1001
♦ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWR Undergrouod Injection Control(IUC)
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
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
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
V
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018
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