GW1-2022-08256_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON �Ya.WATERZONIu
Well Contractor Name FROM TO DESCRIPTION
2930-A 30 it. 35 rL BROWN SAND 1a, 2
it. rt
NC Well Contractor Certification Number 15:OU1ER`CASIHG fo?mnln cased wells"ORhIlVER''tf:a"lieable =
J P ENTERPRISE FROM I TO I DIAMETER I THICKNESS MATERIAL.
+1 ft 130 ft 11.25 1Sdr21 JPVC
Company Name FROM TO
TIIBIlAIGE
353912 ARHS Tbetmal dosed loo � I _
2.Well Construction Permit#: TLncxivEss 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
FROM TO DIAMETER -�SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30 n- 35 fL 1.25 i° SCH40 0.010 PVC
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) fL 30 g• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GRbDT_._.
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 'L. 20 ft- 3/8 HOLE PLUG GRAVITY
❑Monitoring ❑Recovery fL It.
Injection Well:
ft It.
❑Aquifer Recharge ❑Groundwater Remediation
:WSAND/GRAPEI PACK-(If a"licabli
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPI ACEMENTD'IET IOD
❑Aquifer Test ❑StormwaterDrainage 20 ft. 35 ft #2 SAND IGRAVITY
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20--7lRILLING2ZaG attacti-additionsiaheets ifaecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne soillrock in ' eft.
)0 rt 10 ft DARK BROWN/CLAY FINE SAND
4.Date Well(s)Completed: 3/22/22 weu ID#353912 10 35 BROWN SAND COURSE
5a.Well Location: ft. fL
JAMES&SHELLY PRINGLE ft. ft. 1 M 1._
Facility/Owner Name Facility ID#(if applicable) ft. fL
102 RUDDY LN KNOTTS IS NC ft. ft
Physical Address,City,and Zip ft. ft. k Aof*jafion Processing Unit
CURRITUCK 078A00000160000 -,21.,RE MARKS .`
County Parcel Identification No.(PIN) SEPTIC NOT INSTALLED AT TIME OF DRILL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36 29 07 N 75 55 27 w 3/22/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Si ificVVell Contractor I Date
Sys ing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A CAC 02C.0100 or 15A NCAC 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 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: 35 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
10.Static water level below top of casing: +6 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"
lnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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) 30 Method of test: PUMP Permit Program,1611 MSC,Raletgh,tNC 27699-1611
13b.Disinfection type: 73%HTH Amount: 1.2 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018