GW1-2022-06791_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14wATERzoNEs r, , -
Well Contractor Name FROM TO DESCRIPTION
2930-A 54 fL 60 n- LIGHT.GREY SAND
ft. ft. j
NC Well Contractor Certification Number y153sOf1TER"CASiNC(for[ l�crised+tiells OR'LiNER lf:a"'Lcable
J P ENTERPRISE FROM To DIAMZrER TIICKNE.SS MATERIAL
+1 fL 54 fL 1.25 j ISDR21 JPVC
Company Name
368362 ARHS o-16:7NNERCASiNG'ORTDBINC eotherruai'closedaoo # ?;4 . _. a'+' . '
2.Well Construction Permit#. FROM TO DLNfEIER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Cormry,State,Variance,etc) ft fL rn'
3.Well Use(check well use): iL it. ; in.
Water Supply Well:
17:'SCREEN. .
FROM TO DIAMETER SLOT SIZE 7ffiCIC�"ESS ALaTERTAI,, ^
❑Agricultural ❑Municipal/Public 54 ft- 60 fL 1.25 in,j .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single) fL 54 ft in.i
❑Industrial/Commercial ❑Residential Water Supply(shared) 48:;6ROUT r,..%+,.��*_, ',_ .z�• 'sa ,,.... ,' nor s -.� .,.x.,1'`�'
❑hrigation ❑W ells>100,000 GPD rROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
-- — -Non-water Supply Well: - - - - -" - 0 ft--20 ---ft- 3/8 holeplug GRAVITY_-200 LB - — -
❑Monitoring ❑Recovery ft. R- BRNTONITE
injection Well:
IL ft.
❑Aquifer Recharge ❑GroundwaterRemediation
'-19:SANDIGRAVEL PACK.(ifa 'licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAIPLACEMEN`rMETHOD
❑Aqui£erTest ❑StormwaterDrainage 20 ft 60 ft #2 SAND IGRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
i
❑Geothermal(Closed Loop) ❑Tracer 20rDR111ING'LOG attach'add;tiotial`sheetsifnecessa _.4„- ":
❑Gcothermal FROM TO DESCRIPTION color,hardness.soillrocktype� size,etc.)
(Flcating/CoolingRctum) ❑Othcr(tatplainnndcr#21 Remarks) 0 ff 18 ft BROWN SAND
4.Date Well(s)Completed: 6/1 3/22 Well 1D#368362 18 ft• 32 ft• BROWN SAND, GREY SAND
5a.Well Location: 32 ft• 46 rt• FINE GREY SAND CLAY
ROY GIARRUSO 46 fr. 60 ft- COURSE LIGHT GREY SAND
Facility/Owner Name Facility lD#(ifapplicablc) % ft .--.� rf^'
122 WHARF RD fL ft. 5 C T
Physical Address,City,and Zip fL it.
CAMDEN
1t+n r�
County Parcel Identification No.(PiN) DYNrs`O 4
1�1 ULMi'19 UNIT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lot/long is sufficient) Ce tification:
36 14 23 - N 7601 51 W - 6/13/2022
6.is(are)the well(s): CJPermanent or ❑Temporary SiDtje ofCenifie We Co., r Dale
— -- — — Bpningthis form,-Ihereh)•certifythatthenril(.$)mac(here)constructedin accordance with
7.is this a repair to an existing well: ❑Yes or Mo 15CAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
jthis is a repair fdl out known well construction iujormadon and explain the nature of the of this record has been provided to the well miner.
repair under#21 remark"v 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 l GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).' of,may also attach additional pages if necessary.
drilled: 24.SUBMrfTAL INSTRUCTIONS
9.Total well depth below land surface:60 (ft.)
For multiple welb list all depths if different(example-3@200''and 2@lull) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to of casing: 4-7 FT (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijxater Icnrl is above casing,use"+"
p g !
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWI?,Underground 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: PUMP
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type:730
o HTH Amount: 1.5
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