GW1-2022-00296_Well Construction - GW1_20221222

WELL CONSTRUCTTON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON Cn
Well Contractor Name °" 9 } FRO11 TO DESCRIPTION
2930-A DEC 2 2�22 60 it 70 n GREY SAND,SHELL SPECS 1A, 1,2
ft. ft �
NC Well Contractor Certification.Nurnber I ;( .,i5.`t)IiTEfi[a'iS1\C,for_iiiltt eiasetl. eAs QRl Ii�ER fa""' pbte)
J P ENTERPRISE titi�3iff` ut Tl 1'rc�c ,s 3 l r.. FRO1t TO D16"Im TmCIM-Ss MATERIAL
Dy.1i�r8C3O +1 it. 60 rt• 2 SDR21 PVC
Company Name
I�R�
ARHS # 384771 ��t�z,Am>;h�'oR-�UB1NG � �l��t.t tbe<inaton
2.Well Construction Permit# moil To mA11IL"I M TIRCt41E.SS MATERIAL
List all applicable well constriction permits(Le.VAC Carew,State,V-iance,etc) & R rn'
3.Well Use(check well use): ft. fL °'
Water Supply Well: 17 SCItEEN. ,�' .;4 {5
FRO.\[ TO DIM41KI & SLOT SUM IMCK.NESS AL.ITERIAL
❑Agricuttitrai QlrlunicigaUPublic 60 it 70 n 2 in' 010 SCH40 JPVC
QGeothetmal(Heating/Cooling Supply) InResid-dial Water Supply(single) ft- 60 g
❑IndustriaUCommercial QResidential Water Supply(shared) t8:GRt)UT.
❑irrigation ❑Wells>100,000 GPD FROM TO NIATERML' Fl.@Le1CF-M&i r MEIHOD&AMOUNT
Non-Water Supply Well: 0 tr. 20 ft: 3/8 holeplug.GRAVITY
❑Monitoring QRecovery rt ft- BENTONITE
Injection Well:
it ft.
❑Aquifer Recharge QGroundwater-Remediation
QAquifer Storage and Recovery ❑Sa11DIty Barrier FRO1I TO MATERIAL I EMPLACEMENT arETHOD
❑Aquifer Test ElStormwaterDrainage 20 it 70 ft- #2 SAND GRAVITY
❑Experimental Technology QSubsideace Control IL &
❑Geothermal(Closed Loop) ❑Tracer '4V'nt21ti11nGIoG( ht iiddi600alstieetsif.+
QGcothermal(Hcating(CoolingRetum) QOther(cxplain under#21 Remarks) FROM TO DESCRIrrtox color,lmrdnen.solurocr: sire etc.
0 n 13 it BROWN'SAND
4.Date Well(s)Completed: 12/9/2022 Well 1D#384771 13 25 tt COURSE GREY SAND
5a.Well Location: 25 rt 33 e• FINE GREY SAND/CLAY
JENNIFER WRIKER 33 ft 58 f- CLAY
Facility/OwncrNac 1iitylD#('ifapptuablc) 58 it 70 it SHELL SPECS/GREY SAND 1. 1A m ag
1359 NORTHSIDE ROAD ELIZABETH CITY NC 27909 fL ft
Physical Address,city,and zip 73 it 122 0• DARK GREY CLAY
PASQUOTANK 79977114559 y21:t i(tAftrs...; ., �:..q
County Parcel Identification No.(PM EXPLORITY DRILL 73'TO TBD-122'CLAY/SHELL SPECS
5b.Latitude and longitude in degrees/minutestseconds ordecimal degrees: LOW TO NO WATER YIELD
(ifNvell field,one lat/long is sufficient) 22. cation36 23 24 N 76 18 40 W �'' 12/9/2022
6.is(are)the well(s): ClPermanent or QTemporary S tare ofee ' ed ell C r Date
signing thiqfarm.I hereby certify that Ike nr/l(v)ivas(were)cansrructed in accordance Wilt
7.Is this a repair to an existing well: ®Yes or QNo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Neil Construction Standards and that a copy
ff this is a repair,fill out known i eU consevction information and explain the nature Dfilne of this record has beers provided to the well ou ner.
repair under#21 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
construction,only 1 GW-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:70 (ft) 1'
For multiple wells list all depths ifdi(jerent(example-3@zoo'and 2Q10t1) Submit this GW-i within 30 days of well completion per the following:
+6 24a. For All Wells: Original for to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
i
11.Borehole diameter:6 24b.For Injection Wells:Copy toIDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:M U D ROTARY
24c.For Water Supply and Op op Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable;direct push,etc.) county environmental health department of the county where installed
i
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(gpm)20 111eUroa of testi PUMP
13b.Disinfection type:73% HTH Amount: 1.5 OZ
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