GW1-2022-06905_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j.
JOHN PAUL SIMPSON
Well Contractor Name FROM TO I DESCRIPTION
21 iL 25 IBROWN SAND
2930-A ft, ft.
NC Well Contractor Certification Number AS AUTER'CASING;'for malhc-ed\Ve113:OR LTNER(fra"`hcable
J P ENTERPRISE FROM To llIAAtEfER THIcxNe.Ss AtATERI►L
Company Name
+1 it, 121 R 2 ISDR21 JPVC
,.
a I6:TNN
366175 ARHS ' ERiCASiNG;iOR.TUBINC.0 a""ot6erutal ctosedaoo is
2.Well Construction Permit#.. FROM To DIAMETER ! THICKNESS MATER1Ar,
List all applicable well cmesnvction permits(i.e.UIC,Cowzo Stale,variance,etc.) ft. ft, I in.
3.Well Use(check well use): fL ft. C tl
Water Supply Well:
17iSCREEN
FROM TO DIAAETER SLOT SIZE THICKNESS "ATER AL V(
❑Agricultural ❑Municipal/Public 21 ft, 25 fL 2 in. .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) 2aesidential Water Supply(single) ft 21 & in.
❑Industrial/Commercial ❑Residential Water Supply(shared) i8sGROUP.
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ]EMPLACEMENT METHOD&AMOUNT
t• `
Non-Water Supply well: - -- - 0 I 20 . - -ft- 3/8 holeplug GRAVITY 180 LB
❑Monitoring ❑Recovery ft. ft- BRNTONITE
Injection Well:
IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
119:SAND/GRAVEI PACIi'(if:a licsble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENIPLACENIENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 20 IL 25 It• #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft. 3-50LB BG
❑Geothermal(Closed Loop) ❑Tracer 30.Dit1Lil\GLOG'attacKadditibinili lieu iiriecess
❑Gcothcmtal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock a sire,etc.
o IL 10 It• BROWN BAND
4.Date Well(s)Completed: 5/18/22 well ID#366175 10 it• 25 It• BROWN'SA ,- fJ ,V y
5a.Well Location: jut
CHRISTOPHER EAST fL it. 2022
Facility/Owner Name Facility ID#(if applicable) ft H.
176 N SPOT RD fL ft.
Physical Address,City,and Zip fL ft.
CURRITUCK 01230000890000
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �C'e tif"rcation:
36 07 40 N 75 49 50 W
• 5/18/2022
6.1s(are)the well(s): ❑Permanent or ❑Temporary Si ture of Cc. We Conuac r Date
- By i ning this form,llterehl•certify that the w ell(.v)was(here)convtructed in accordance with-
7.is this a repair to an existing well: ❑Yes or MNo 15 CAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a cvpy
#'Ibis is a repair,fill out Ianomi wall construction information aid explain the nature of the of this record has been provided(o the well ouver
repair under 1121 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 inf
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.Totai well depth below land surface:25 (ft.)
For multiple welly list all depths iij'di/fereni(example-3 aGl�00'and 2Q10(Y) Submit this GW-1 within 30 days of well completion per the following:
+5 FT 24a. For All Wells: Original forin Ito Division of Water Resources (DWR),
10.Static water level below top of casing: 0L) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing rue"+" 1
il.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Weiss:Copy to the
(i.e.auger,rotary,cable,direct push•etc.) county environmental health departr`rent 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 Progratn,1611 MSC,Raleigh,NC 27699-1611
0
13b.Disinfection type: 73 o HTH Amount: 1.5