GW1-2022-00266_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON
FROM TO DESCRIPTION
Well Contractor Name
2930-A 21 ['- 24 #2 COURSE LIGHT BROWN SAND
• f
NC Weil Contractor Certification Number _tS'OBIERG►Si4G(for.'mut6crisedrS'elts OR<LiNER ifa""bcable
J P ENTERPRISE FROM TO DIATIEFER , I TMCKP'ESs aATERIAL
+1 f'• 121 ft- 12 ISDR21 PVC
Company Name
ARHS 379251 =:�Tt>:,I�I� �s�R� GoR:It1R1>YC
2.Well Construction Permit#: FROM TO DIAMETER I TFFICELNTM MATERIAL
List all applicable well construction paimits f.e.WC Cormoy State,I-arlance,etc) R tt• in
3.Well Use(check well use): ft. ft. in.
Water SuPPlyWell:
FR03I TO DMOIETER SLOT SIZE TMCK.NTSS \LXIERIAL
❑Agricultural ❑Municipal)Public 21 n' 24 fL 2 in .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) fL 21 fL tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) u
❑.Irrigation 0Wells>100,000GPD FROM TO MATERIAL J EIIPLACE.1IENrMErnoDB.%MOONT
Non-Water Supply well: 0 [� 20 fi- 3/8 holeplug GRAVITY
❑ivionitoring ORecovery 11. ft- BENTONITE
Injection Well:
[6 ft.
❑Aquifer Recharge ❑Groundwater Remediation
.:;19SANl)1GR�VEIPACK da licaliie � t,=s:1�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD `
❑Aquifer Test ❑StotmnaterDrainage 20 ft 25 fL #2 SAND GRAVITY
❑Experimental Technology 13Subsidem a Control f ft-
❑Geothermal(Closed Loop) ❑Tracer 20.DRILf h\G'L`O'G(attacfi'uddidLual s6eefs if ueressa }+
❑Gcothcrrnal(Ficating/Cooling Return) ❑Other(explain under lr21 Remarks) FROM TO DESCRIPTION(color.hardness,sollfinek size,etc,)
0 12 fr- DARK BROWN SAND
4.Date Well(s)Completed: 12/19/2022 WeR M9 379251 12 FL 19 rL BROWN SAND
5a.Well Location: 19 rL 25 ft- LIGHT;BROWN SAND
JOHN WARD JR `L ft.
fL
Facitity/OwnerName Facility1D (ifapplicable) 0• -
100 HAVEN LN POWELLS POINT
Physical Address,City,and Zip fL f4 DEC 2
CURRITUCK 0123000120F0000 22ERPFARi►S'".'N' ;',.Lr..
County Pawel Identification No.(PIN)
{ilrCiiFt4f3+d�f1 eft`:
rr ,
5b.Latitude and longitude in degrees/nI untes/seconds or decimal degrees:
(ifwell Yield,one lattlong is sufficient) 2N Certifrntip
360743 N 75 49 26 WA _ ft_JL
(` 12/19/2022
6.is(are)the well(s): QPermanent or ❑Temporary Si ifCert well Contractor Date
By ngthirfnrm 1 hemlry certify that the xvell ft)nays(urre)constructed in accordance adth
7.IS this a repair to an existing well: ❑Yes or CiNo, 15A A C 02C.0100 or Li4 A'CAC 02C;,.0200 li ell Construction Standards and that a copy
IJthis is a repair,fill out known well construction u+formation and erplain the nature of the of this reeord has been provided to the nei11 miner.
repair under#21 remarks section or an the back ofthis farnL
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 i 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:25 (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple nr1h list all depths ifdi�erent(example-3Q200'and 2Q10(Y)
water level is above casing,rise (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
ff Static water level below top of casing: (ft.)
Information Processing Unit,]617 MSC,Raleigh,NC 27699=1617
If "+"
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWR,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
(Le.auger,rotary,cable,direct push,etc.) county environmental health departmcnt of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield��pm)30 Method of test:PUMP
13b.Disinfection type:73% HTH Amount. 1.5 OZ