GW1-2022-00295_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW 1) For internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON TwnTErtzoNEsi .h:r� rr...,� <. .a
Well Contractor Name I FROM 70 DESCRIPTION
2930—A � ,�, 5 ►�-� 50 �- 55 ft- COURSE LIGHT GREY SAND 1A.2
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NC Well Contractor Certification Number c r 2 J `J&OU EWCAST\c rotmulh cased';aells'ORLINER'tGa "livable
J P ENTERPRISE FRONT TO DL"FETER THIDINTM A(ATERTAL
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Company Name = �7 `�>v:»' +1 fL 50 2 to sdr21 pvC
IRivi iYfeSti<�'
6-yrq��� �1fbsTR'NER.CASiNC OTtrTUBTNC_ edt6er`ti8t ellised-Ioo %r=�'
2.Well Construction Permit#: NA FRONT 110 DTAA[MR THICKNESS AtATERLIL
List all applicable well construction permits(Ie LUC,Cowl%Srme,Variance.etc) fl. Tt is
3.Well Use(check well use): iL fr. to
Water Supply Well: .f7`$CREE\
FROM TO DIAMETER SLOTSIZE' THICIC\TM NUTERIAL ,
❑Agricultural O'Mumcipal/Public 50 ft• 55 fL 2 i- 010 SCh40 PVC
CJGeothermal(Heating/Cooling Supply) DResidemial Water Supply(single) N- 50 &
❑lndustrial/Commercial GResidential Water Supply(sham,
01nigation ❑Wells>100,000 GPD FROM 'to SIATERMI. z MPLACEAIEIS'r=TROD&AMOUNT
Non-Water Supply Well: 0 n 20 ft 3/8 hole plug GRAVITY
❑Monitoring ❑Recovery rL R• BENTONITE
Injection Well:
EL rt.
❑Aquifer Recharge QGroundwater Remediation
'iI9,S�NDIGR:1,�!EC•PAC1►(ira liiyble}z,, .. �`� �` r. ,
[]Aquifer Storage and Recovery ClSalinity Barrier FRONT TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDminage 20 it. 55 ft- #2 SAND IGRAVITY
❑Experimental Technology ❑Subsidence Control fL
❑Geothermal(Closed Loop) ❑Tracer 20 DR1LLMG COG'(attiietiVddit!6 PSN&tadnecessa ~'
❑Gcothermal(Heating/Cooling Return) ❑Other(explain under in Remarks) FROM TO DESCRIPTION(color,hardness,soiUmck sire,etc.)
0 % 13 ft CLAY BROWN SAND
4.Date Well(s)Completed: 10/19/2022 well ID# 13 ft- 25 f. FINE GREY SAND CLAY
5a.Well Location: 25 ft. 42 fr. CLAY
TOM & LYNN NASH 42 fL 57 f' CORSE LIGHT GREY SAND
Facility/OwnerName FaciilityM#(ifapplictblc) R' ft'
117 NIXONTON LOOP ELIZABETH CITY, NC fL ft. r
Physical Address,City,and Zip fL fL 1
PASQUOTANK r, }.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if-well field,one IaUtong is sufficient) 22.iez6on:
361157 N 76 16 25 W 10/19/2022
6.Ts(are)the well(s): ❑Permanent or OTemporrry Sicm� ofCettified WCoilfor ii Date
Bysi dng this fmnr,I herehy certify that the urll(.c)uns(it-Ile)constructed in accordance ivith
7.Ts this a repair to an existing well: LIYes or ❑No 15A 1C 02C.0I00 or 15A NCRC 02C.0100 Hell Construction Standards and that a copy
If dris is a repair,fill out larmt-n xrll construction hiformation and etplaia the nature of the of this record has been provided to die hell miner.
repair tinder 021 remarl s section or on the backofthIs fomc I
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 OW-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:55 Submit this G%V-1 within 30 days;of well completion per the following:
For multiple ivelb list all depths if different(example-3Q200'and 2Q/(10)
+9 ts 24a. For All Wells: Original form to Division of Water Rourccs (DWR),
10.Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter- 6 (�.) 24b.For Iniection Wells:Copy to I)WR,Underground Injection Control(IUC)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD For Water Supply and Open=Loop 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield Cgpm)25 Method of test:PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b,Disinfection type:73% HTH Amount: 1.5 OZ