GW1--08046_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Daniel Veltri 14..WATESZONES I ., .hi.`.:M/>r ..gffiitA. )k.r€ t,... :4 ,v.>M-t` At
Well Contractor Name
FROM TO DESCRIPTION
16 ft- 25 ft- r s..I
4368-A
ft. ft
NC Well Contractor Certification Number .45::OVTERCASING.(for•iu67ti#cased'weHa)'OICLINER(if— le).`^'IRir-V
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
1 ft- 21 ft' 11/4 m' sch-40 pee
Company Name
40.3153 =.16 NER CAS NG OR TURING(geauzrtha►dosed=loop) .ems`,3; ., .c
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): It. ft. in
`,17
Water Supply Well: .'=SCREEN, 4<� ,. .4 . ._:�;,., .4 z , w-t:# . , .,�
FROM TO DIAMETER SL.OTSIZE THICKNESS MATERIAL
111 Agricultural OMunicipal/Public ,, 21 ft. 25 - it. 11/4 in" _010 sch40 pvc
•Geothermal(Heating/Cooling Supply) Eilliesidential Water Supply(single) ft. fL flu.
ilndustrial/Commercial DResidential Water Supply(shared) tIt'GROl1T,, r . -..n.._ y Y_ _ t W ' 7 F. , .i.. , %
Irrigation , _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 R- 20 ft= hoteplug -
•lMonitoring ()Recovery ft. ft.
Injection Well:
ft. ft.
golfer Recharge OGroundwaterRemediation ;19:SAND/GRAVEL PACK(iif applicable) „i„h 4G l h III r u Storage and Recovery ()Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
•;Aquifer Test OStormwater Drainage 21 ft. 25 fL DSt1A' gravity
II Experimental Technology DSubsidence Control ft. ft.,
i1"Geothermal(Closed Loop) °Tracer 020:'DRi1 LING;I:OG`(att chudd'ulainalsheetaifuecessa y)v..,.. 3 ns i v.::6,.. l
IIIGeothermal(Heating/Cooling Return) ()Other(explain under 421 Remarks) FROM TO DFSCRIPIION(ado,hardness,sax ocl�type,grain s1u etc.)
1 ft. :2' ft• brown day.
4.Date Well(s)Completed:5 Dec 23 Well>I7HI 2 ft• 13 ft• yellow sand 1.---;,
� _
Sa.Well Location: 13 ft. 14 ft- Peat Mss ,t
o ' ,rT 'e 17"' `Y i "'!(1 )-4
� .y
Kyle Fox t4 ft. 16 ft• Gray Clay (}r
Facility/Owner Name Facility ID#(if applicable) 16 ft. 2: ft. gray sand U r C I t0 C U L)
116 South End Rd,Knotts Island,27950 ft. ft.
Physical Address,City,and Zip ft. R. D d O. C' '
Currituck 21A1EMARxs N. _ . .hr_V. x r• #_.Wr r `q,1.` sue'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) --- 22.Certification:
36.51010 N -75.92589 W
(CPC.2 3
6.Ls(are)the wel(s) Permanent or Temporary of Certififd W Date
By signing this fain,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2l 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 baying the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgerent(example-3 a@200'and 2Q100') construction to the following:
to.Static water level below top of casing 13' (f.) Division of Water Resources,Information Processing Unit,
If outer level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter.5 718 (in.) 24b.For Inflection Wells: In addition to sending the four to the address in 24a
Mud rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)20__ Method of test:pacer pump 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
t 13b.Disinfection type: hypochnte Amount: 3 Os completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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