GW1-2021-02725_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 DESCRIPTIONI
2930-A 55 IL 60 ft.
NC Well Contractor Certification Number
-15.OUTER CASING(for Juulfi�casedwells)OR LINER Of 6-0
J P ENTERPRISE FROM I TO I DIAMETER THICKNESSMATERIAL
Company Name +1 ft- 155 ft- 12 �in. i - IPVC
,16.INNER CASING OR TUBING(zeiitherinal closed-loov)
2.Well Construction Permit#: 361474 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.EflC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. M in.
-
Water Supply Well: 11SCREEN'l-
FROM TO DIAMETER SLOT S12E THICKNESS MATERIAL
DAgricultural r]Municipal/Public 55 ft- 60 ft- 2 in. .010
DGeotherinal(Heating/Cooling Supply) MResidential Water Supply(single)
fL 55 ft-
01ndustrial/Commercial OResidential Water Supply(shared) 18;GROUT-
ObTigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 3/8 holeplug
ClMonitoring ORecovery fL fL BENTONITE
'Injection Well: ft. fL
OAquifer Recharge 043roundwater Remediation
19.SAND/GRAVEL PACK if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test OStorrnwater Drainage 20 ft 60 iL #2 SAND DS1
OExperimental Technology El Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional Sheets if necessary)
0 eothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness�soiltrock tyM grain size,em)
0 It- 24 ft
4.Date Well(s)Completed: 7/25/2021 well ID#361474 24 ` 48 rt
5a.Well Location- 45 IL 60 ft.
WILLIAM VARGAS ft. ft.
Facility/Owner Name Facility 1D#(if applicable) fL M
6242 CARATOKE HWY GRANDY NC 27939 fL M
Physical Address,City,and Zip ft. ft.
CURRITUCK 21.REMARKS
P
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
361506 _N 75 53 29 W
6.Is(are)the well(s): InPermanent or OTemporary Si tune of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ItYes or ONo 15A MCAC 02C.0100 or IJA JVCAC 02C.0200 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You u may also attach additional pages if necessary.
drilled'' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iftlifferent("ample-3@200'and 2@1001
10.Static water level below top of casing; +9 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
�7699-163
12.Well construction method: MUD ROTARY Program,1636 MSC,Raleigh,NC 1 1
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: PUMP Permit Program,
1611 C,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018