GW1--04030_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2930-A 42 ft- 52 ft- COURSE GREY SAND/SHELL SPEC
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft' 42 ft- 1.25 i"• SDR21 PVC
AR H S P# 407406 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. I ariance,etc.) ft. R• In.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 42 ft- 52 ft' 1.25 in. .010 SDR40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R• 42 ft. ;n,
❑industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 4 ft- 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft- BENTONITE 60LB-SLUMP FILL
Injection Well: 4 ft. 40 ft• BENTONITE TREMMIE/PUMP
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 40 ft- 52 ft- #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
O Geothermal(Heating/Cooling Return) ❑Other(explain under#2 i Remarks) FROM TO DESCRIPTION(color,asrdness solVtock type grain size,etc.)
0 ft' 13 ft- DARK BROWN SAND
4.Date Well(s)Completed: 6/28/2024 Well ID# 13 ft- 32 ft- FINE GREY SAND/CLAY
5a.Well Location: 32 ft- 40 ft. GREY SAND I SHE r
SUSAN FRED 40 f` 52 ft- LIGHYT GREY SAND 1 6Pb"E L)
Facility/Owner Name Facility ID#(if applicable)
ft.
.1UL 0 8 2024
103 CACO ST JARVISBURG NC 27947 k• ft.
Physical Address,City,and Zip ft. ft. IG .:n-4i 7A 1'r' 4.4-EI Ufa
CURRITUCK 110A002005A0000 21.REMARiCS `'a3i^"
NCDHHS VARIANCE#
County Parcel ldentificationNo.(PIN) WWM1805, WWM1848
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificati
36.16624 N 75.86606 w 6/28/2024
•
Is(are)the wells: ['Rermanent or ❑Tem ra Si tore of Ceni Well Conua'cior 1 Date
6.is )( () Po ry
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
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: 52 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple sells list all depths if different(example-3®200'and 2(0100')
+6 24a. For All Wells: Original form 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"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 tin.)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
20 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: PUMP
13b.Disinfection type: 73% HTH Amount: 1.0 OZ
Form GW-I North Carolina Department of Lncirunmental Quality-Division of Water Resources Revised 6-6-2018