GW1-2022-00260_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW 1) For intemat Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON
,tii4t;WATER,'LONF,$0F rY,:t S,*�;=«?Sr
FROM TO DESCREM0N 1
Well Contractor 21 f/. 24 R- COURSE BROWN SAND
2930-A ,�.
NC Well Contractor Certification Number a5Si0UCERiCaSi YC`for`:in IIIavSed wells,Oil LTNER{if a hcable "'
J P ENTERPRISE FROM TODIAAIt IER11 TRICKNESS DiATERIAL
Company Name +1 it. 121 iti 1.25 '° SDR 21 JPVC
ARHS 382090 fiA&TNNERCASiNG OR:TIIBiNC(eotl ermiil cinsedaoo .,a`s r ', ,.k.
2.Well Construction Permit ff FROAi Tn DLWIEIER, MUCKNTM I MATERIAL
List all applicable well constrwflon permits(le.UIC County,State,Variance,etc) M R. is
3.Well Use(check well use): ft. It. 111-
Water Supply Well:
FROM TO DIAM 3M I SLOT SIZE TMC106TM NUTERIAL
❑Agricultuml ❑NiunicipaUPnblic 21 Il 24 n• 1.25 in' :010 SCH40 PVC
❑Geothermal(13eating(Cooling Supply) 19Residemial Water Supply(single) ft- 21 in.
❑industriai/Commercial ❑Residential Water Supply(shared) .,.,1 ,GItOIIT
❑lrigation ❑Wells>100,000GPD FROM TO MATERIAL EIIPIACENIENr1%WIHOD&AMOUNT
Non-Water Supply Well: 0 fr. 20 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery % n• BENTONITE
Injection Well:
It- fL
❑Aquifer Recharge ❑Groundwater Remediation
193SA.NMIGRAVM-TACK(ifap cable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL- E.MIPLACEMENT METHOD
❑Aquifer Test ❑StommnaterDrainage 20 ft 24 ft. #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Contml tt ft,
❑Geothermal(Closed Loop) QTracet 20;bR1G111VG' (? utrierailaitiuonl.'s`heetsif ).5,- =
❑Geothermal(Heating(CoolingReturn) ❑Other(explain undcrn2lRemarks) FROM I To DESCRIPTION(color,hazAamsoiuroct e, slze,era
11/15/22 382090 0 4 13 n BROWN SAND
4.Date Well(s)Completed: WelI Iw 13 24 BROWiV SAND
5a.Well Location: i<• R'
BRITTANY AND WADE MARKEL
Facility/Owner Name Fsci ity 1D;f('tfaMlicable) it. fL
LOT 4 SASSAFRAS LN SHILO NC ft. ft. ET
Physical Address,City,and Zip % fL
CAMDEN 038972004935450 _,,::..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal,degrees:
(if well field,one lat/long is sufficient) 22.Cer ifiication.-
36 16 05 N 76 02 00 W >
� 11/15/2022
6.is(are)the well(s): nPermanent or OTemporary Si ure ofCcrelasd WenCont=tor Date
ByANingthisfarm Thereby mrlifythatthe xrl/(.$)nos(nrre)canstrtreted in accordance 011,
7.is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.01 DD or 154 4C 02C AZ00 N ell Construction Standards and that a copy
Ifthis is a repair,fill met known x-ell consaaction information and erplain the nature of the of this record has been provided to the uvell mmmer.
p
repair under#21 remarks sectian 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 l is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You;may also attach additional pages if necessary.
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drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:25 01•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(erample-3@200'and 1@MY)
+5 24a. For All Wells: Original form to Division of Water Resources (DAFR),
10.Static water level below top of easing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use f
11.Borehole diameter:6 (;n•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
MUD ROTARY Program'1636 MSC,Raleigh,NC 276994636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.anger,rotary,eable,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
PermitP,vgram,1611 MSC,Raleigh,NC 27699-1611
132.Yield(gpm)20 Method oftest:PUMP
13b.Disinfection type:73% HTH A.M. 1.5 OZ
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