GW1-2022-10634_Well Construction - GW1_20221128

WELL CONSTRUCTION RECORD(GW-1) For Intemal.Use Only
1.Well Contractor Information:
Daniel C.Veltri 14.WAIMX
Well Contractor Nam FROM I TO I DESCRIPTION I
55 R. 67 fl.
NCWC 4368-A
fL
NC Well Contractor Certification Number (L
15.OUTER CASINGfor multi Bided OR ifaRqUeldile)
Maupin Well Drilling LLC FROM MATERIAL
Company Name "1 67 R. 1 2 in. I P,206 PVC;- 7
,DMRCASINGOR.MING4&offiermaidoiep) : , , i
2.Well Construction Permit#:3 16 "ifo
75431 FROM- TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(11 e,UIC,County,State,Variance,etc) ft. R. in.
3.Well Use(cheek well me):
17.SCREEN
Water Supply Well: FROM T TO DIAMETER SLOT SIZE TMCKKM 1 MATERIAL
Agricultural [3MunicipaMblic 57 fL 67 ft' 11/4 tit' .010 sch4o pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial 1311csidentiall Water Supply(Shared) ,
I&GROUT
I litigation FROM TO MATERIAL EMPLACEMENT MLIMOD&AMOUNT
Non-Water Supply Well: 1 57 R Hotwug Gravity
Monitoring Recovery ft. ft.
Injection Well: M ft.
Aquifer Recharge [3Groundwater Remediation 19�SAND/GRAVEL PACK(de`0plicatife)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL F24 L PI I ACEMEN IMETHOD
Aquifer Test 13Stonnwater Drainage 57 ft- 67 fL to GrdlfftY
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) OTracer 20.D LOG(attach additional sheets Ifnecessary)
I TO DESCRIMON(mlor,hiirdness.wlvmk type�grain virr,etc.)
Geothermal(Hcating/Cooling Return) Other(explain under#21 Remarks) FROM
i( . I fL 6 ft- Gray/Brun day
4.Date Well(s)Completed:17 Nov 22 Well ID# 6tt 28 it, yellow sand
5a.Well Location: 2% ft. 53 fL Gray Clay
David Kurfich 53 R. 54 ft. boo D,tr=
Facility/Owner Name Facility lD#(ifapplicable) 54 ft. , fL Gray Sand
153 Big Bend Dr Moyock,NC.27958 ft. fL NOV 2 8 2022
Physical Address,City,and Zip fL
Cuffftck 030B00000230000 11'.REMARKS N,
County Parcel Identification No.(PIN)L W/Q/30G
Sb.Latitude and longitude In degrees/minutes/3 uds or decimal deg
rees:
grees-
(ifivell field,one lavlong is sufficient) 27-Certification-
36.49877790 N -76.092834380
18 Nov 22
Well
Co.
6.Is(are)the well(s)OPernianent or Temporary ­Signa� iui Well Contra-c%T----------- Date
By signing this form,I hereby eadfv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15ANCACO2C.0100or 15A NCACO2C.020 Bell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#21 remarks section or an 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 site details or well
construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 67 —00 24a.For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ifitifferen t(example-3 @200'and 2@ 1 M construction to the following:
10.Static water level below top of casing:6
(ft.) Division of Water Resources,inforniation Processing Unit,
lfwater IeW is above casing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
---I I.-Borehole diameter.-5-7/8--- - -(I,.) 24b— og Injection sending-the todaddrmi _24a Mud Rotary above,also submit one copy of this form within 30 days of completion of well
JIL Well construction method:
construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 20 Method of test paoe,pump 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hypochrite Amount. sm completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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