GW1-2022-00267_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information: j
JOHN PAUL SIMPSON
�,i4H'ATER'ZO;VFS.t, � .;.,�,,,r w.f � .-,. 3.., •.•..
FROM TO DESCREMON
Well Contractor Name 21 ft- 24 n• COURSEI BROWN SAND
2930—A ft. I ft.
NC Well Contractor Certification Number -
i5i'.Oii7ERG4SiNC;formo"I easAIIv ells'.ORiTVER �f:a' l(cable '.
J P ENTERPRISE FROM m D1A1tI m TMCK..NM I 1rATERiAL
+1 fL 21 tt. 11.25 ISDR 21 JPVC
Company Name
ARHS 384127 �.ts�lnvER:casiNcaR:Tirsnvc
2.Well Construction Permit#: FRONT TO DIA59=11 THICKNECS 1MTERML
List all applicable well construction permits fl e:UIC,Chinni;State,Variance,etc) R tL in.
3.Well Use(check well use): tt. ft. in.
a.17::SGREEN._$L. :`..i.' xn, rro,
Water Supply Well:
F11011 TO DIAMElEIt SLOT SUM I MUCK.NTM I AUTF.RIAL
❑Agricultural ❑MUnicipallPublic 21 IL 24 fc 1.25 "L .010 ISCH40 JPVC
❑Geothermal(11eating/Cooling Supply) InResidential Water Supply(single) fL 21 g, in.
❑Industrial/Commercial ❑Residential%Vater Supply(shared)
a�8.ti7t0U1 h ..<>i m a. inl,:'±.,.
❑Irrigation ❑1Welis>100,000 GPD FR011 TO bUTEMAL E11P1-%,CE1tMr r.WMOD&AMOUNT
Non-Water Supply well: 0 f� 20 - 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft. BENTONITE
Injection Wen:
[t fr.
❑Aquifer Recharge ❑GmundwaterRemediation
49:S.4i�'D/GR11'E4PAC[Cfi£if
❑Aquifer Storage and Recovery ❑Salnitty Barrier FROM TO MATERIAL EMPLACEAIENT METHOD
❑Aquifer Test ❑StonnnaterDrainage 20 fL 24 fL #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control f4 fL
❑Geothermal(Closed Loop) ❑Tracer s7A DR1i I IL�OIOG(dttacti siddttiouaisheetsifuecessafi a `w
❑Gcothcmral g ) FRO31 TO DESCRWTION(color.hard soi0rocii a i' size etc.)
(Heating/Cooling gRctam ❑Othcr(tacplainnndcr#21 Remarks) 0 ft: 10 fr' BROWN SAND
4.Date Wett(s)Completed: 14/21/22 %va ID#384127 10 ft. 25 m BROWN SAND
n e.
Sa.Well Location:
PEGGY NEWBERN `� it. r.=.,(...s-6 i E D
Facility/Owner Name Faci1ity1D?(ifa0li-blc) & fL
8355 CARATOKE HWY POWELLS POINT NC 27966 ft- ft. _.• 2 2
2022
Physical Address,City,and Zip it. f• r{{{ jD 1 r
CURRITUCK 012400000320000
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i£Avell field,one lat/long is sufficient) 22.Certification:
36 07 18 N 75 49 59 W 11/21/2022
6.Ts(are)the well(s): MPermanent or ❑Temporary Si of ed well Contractor Date
By -gthisfam;l hereby certify that the uell(s)ims(were)constructed in accordance with
7.is this a repair to an existing well: 19Yes or ❑No 15A NCAC 01C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fdl out latown Nell construction information and erplain the nature of the of this record has been provided to the well miner.
repair under 021 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
(add'See Ovee in Remarks Box).'ou may also attach additional pages if necessary.
construction,only 1 GW-1 is needed, indicate TOTAL NUMBER of wells i
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:24 (ft.)
For multiple nelir list all depths ifdidereai(example-3@200•and 1@100) Submit this GW-1 within 30 days'of well completion per the following:
♦5 24a. For All Wells: Original form Ito Division of Water Resources (D
WR),
10.Static seater level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1fts wer level is above casing,rise"+"
1t.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 Op IL op Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push.etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodaci I vI r 100,000 GPD:Copy to DWR,CCPCUA
, C 27699-1611
13a.Yield(gpm)30 Method of test PUMP� Permit Ptogtam,1611 MSC,Raiei�h
7
13b.Disinfection type:73% HTH Amcmut: 1.5 OL
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