GW1-2023-01014_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL M SIMPSP ��GA. \fFn
14FaWATER=ZONES :n, 4„
`_` FROM TO DESCRIP,TTON me.
Well Contractor Name
2930-A JAN 2 5 2023 21 24 R #2 COURSE LIGHT BROWN SAND
ft. ft.
NC Well Contractor Certification Number �. q im V ,15.',OUTER:CASING for itiiilti�ased;Welli)ORLINER,itip beable'�. .,
J P ENTERPRISE 'ntofa�ratrQi� FRO\1 TO DIAMETER' THICKNESS MATERIAL
Company Name +1 21 2 in.
" SDR21 JPVC
ARHS 379251 16.-IKNEICCASWODRTusnvG' eothermal:closedloo .... :m,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,M) ft. ft, in.
ft.
3.Well Use(check well use): ft. ,
Water Supply Well: �77 SG'REEN3,�:�, ..... ..... ... ` .. ...,r. ?vx
FROM TO DIAMETER I SLOT SIZE TffiCK_N"ESS I MATERIAL
❑Agricultural ❑MunicipaUPublic 21 fL 24 fL 2 in: .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) MResidential Water.Supply(single) fL 21 ft•
❑Industrial/Commercial ❑Residential Wnter Supply(shared) 18.'GROUT
01rrigation .❑Wells>100,000-GPD FRODI TO 3 MATERIAL} ED1PLnCEhtENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 ft• 318 holeplug GRAVITY
❑Monitoring ❑Recovery fL rt- BENTONITE
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
''.195't1ND/GR11�?$I.P�CK`(it'.a lieAlle) ,.t. .•.'>`'.4'i}_F`�?a'J ..3' -:..� ,k` .._,.-.
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL: EM PLACEbI ENT METHOD
[]Aquifer Test ❑StormwaterDrainage 20 fL 25 it- 42 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control / % ft. 1 I'
❑Geothermal(Closed Loop) ❑Tracer �l DRIL1ANG',J oG(attaelraddltiihi l heetsifneeessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FRO31 TO DESCRIPTION(color,hardness•soil/rock ain she,etc)
0 ft' 12 ft- DARK�BROWN SAND
4.Date Well(s)Completed: 12/19/2022 Wen ID#379251 12 ft- 19 ft- BROWN;SAND
5a.Well Location: 19 fL 25 R LIGHTi1BROWN SAND
JOHN WARD JR Tt• R
Facility/OwwNamc Facility ID#(if applicable) ft ft.
100 HAVEN LN POWELLS POINT ft ft.
Physical Address,City,and Zip % ft.
CURRITUCK 0123000120F0000 ,21REn1ARKS., h, .;'_ .,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if we0 field,one tat/long is sufficient) Certflca
36 07 43 N 75 49 26 W '
12/19/2022 _
~ 6.is(are)the well(s): nPermanent or ❑Temporary Si ofCertifie Well Contractor Date
Bps ng this form,/hereby certify that due well(k)was(here)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or ©No ISA C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that copy
If this is a repair,fill out knoma well construction information and erplain the nurture of tile of this record has been provided to the well owner.
repair under#21 rentarlcs section or on the back of this form
23.Site diagram or additional well de,tails:
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).Y.
may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:25 (ft.)
For multiple wells liar all depths ffditferent(example-3@200'aad 2@I001 Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing:+6 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifiiater level is above casing,rise"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
MUD ROTARY Program,1636 MSC,Raleigh,NC 2 7699-1636
12.Well construction method: MUD
24c.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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 108,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)30 Method of test.• P U M P Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
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