GW1-2021-02708_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14,WATER-ZONES
:
Well Contractor Name FROM TO DESCRIPTION
2930-A 54 ft- 58 rL LIGHT GREY COURSE SAND
rL M I
NC Well Contractor Certification Number 15.-OUTER CASING for multi eased'iSells OR I NER if a licable "
J P ENTERPRISE FROM TO DIAMETER I THICKNESS MATERIAL
+1 ft 54 ft 2 'a- SDR 21 PVC
Company Name 16.;INNER CASING OR TUBING ebthermal closed4ofo
2.Well Construction Permit#: 361452 FROM TO DIAMETER TEnCKNFSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17.-SCREEN _. W
FROM TO _ DIAMETER SLOT SIZE THICIINFSS I MATERIAL,
❑Agricultural ❑Municipal/Public 54 fL 58 tt. 2 `°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft 54 ft 1O' f
❑Industrial/Commercial ❑Residential Water Supply(shared) l8z GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 R' 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. fL BENTONITE
Injection Well:
2 fL
❑Aquifer Recharge ❑Groundwater Remediation
14.'SAND/GRAYEli'PACK ff a licslile ;:• i '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft 58 f• #2 SAND:DSI IGRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
i
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets lif necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIPTION color,hardrin soNruck eta
0 ft. 24 it. BROWN SAND DARK 2-PEAT LAYERS
4.Date Well(s)Completed: 7/28/2021 Well ID#361452 24 rL 48 fL BROWN GREY SAND FINE
5a.Well Location: 48 f' 58 ft- LIGHT GREY COUSE SAND SHELL SPEC
WILLIAM BEASLEY ft. fL
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
670 GRANDY RD GRANDY NC 27939 f. ft.
Physical Address,City,and Zip ft. ft.
CURRITUCK 0096000002B0000 ILLREMARICS =. N V
County Parcel Identification No.(PIN) EXISTING WELL LOW Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification: L�r Sa
36 12 34 N 75 52 48 W n I \nN'O V$�
r..�..,�
6.Is(are)the well(s): InPermanent or ❑Temporary Si tune of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 19Yes 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 known 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: 58 (ft.)
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: +9 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M U D 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: P U M P Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
I
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018