GW1-2021-06991_Well Construction - GW1_20210507

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri 1a:wA7 xzoNEs h ,r Hy;
Well Contractor Name FROM TO I DESCIUMOv
NCWC 4368-A 46 ft. 57 ft.
rt. rt.
NC Well Contractor Certification Number 15 0UTERCASING tormowli c"sM*00R OR,Lam la able
Maupin Well Drilling LLC FROM To DIAMETER THICKNM I MATERIAL
H ft. in.
Company Name Ccc c 16.1NNERCASINGORTUBNG cloaedA
L well Construction Permit#:35 V 696 FROM I TO I ntAMETIM I TH[CIaV&SS 'MATERIAL 1j
Lid all applicable writ construction permits(le.UIC,County,State,Variance,etc.) 1 ft. 47 ft. 1 114 in. sch�a
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN„
FROM TO DIAMEIBR'`•SLDT S12Z THICKNESS MATERIAL
Agricultural 13M micipal/Public f ft h
47 57 t 1/a ooto sdr4o pvc
Geothermal(Heatmg/Cooling Supply) EIResidenfial Water Supply(single) ft, H in.
Indusuial/Commeroial131tesidential Water Supply(shared)
18.GR0UT
hTi 'On FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t fL 46 ft• talephrg gravity
Monitoring Recovery rL %
Injection Well: IL ft.
Aquifer Recharge Groundwater Remediation
'
Aquifer Storage and Recovery Salinity Barrier 19:SAND/GRAVEL PACIC''FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 46 ft 57 ft to gravity
Experimental Technology Subsidence Control R R
Geothermal(Closed Loop) Tracer -20:DRILLINGLOG fittich rdditlemil sh&eft H
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO I DFSCRIMON mtor,hardn sotltrndt n she,etc
1 ft. 8 % gray day
4.Date Well(s)Completed:30 April 21 wen ID# a fL t4 fL fine yam,sand
53L Well Location: w % 20 fL coarse yeom sand
Corey Speer 20 ft. 46 ft gray day
Facility/Owner Name Facility ID#(if applicable) 46 ft• fr• gray sand Coarse
176 Deer Run, Moyock 27958 H- ft.
Physical Address,City,and Zip tL iL
Currltuck 022D000000080000 2LRFArAnuc
Casty Parcel Ideoti6cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
36.51360 N -76.11427 W � 2 may 21
6.Is(are)the well(s)oPermanent or 13Temporary SN re of Certified Well Contractor -�w Date
By signing this form,I hereby certify that the wrll(s)coos(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 13No with/SA NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
If this is a repay,fill out known wail construction information and explain the nature of the copy of this record has been provided to the wr//owner.
repair under#21 remarks section or on the bark 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 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.
dolled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5T 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3Q200'and 2 1001 construction to the following:
10.Static water level below top of easing:4' (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 7/8 00 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
mudrotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e,sager,rotary,cable,direct push,etc.)
Division of Water Resources,Underground I I jection 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&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy ofl this form within 30 days of
13b.Disinfection type: FtyporChttte Amount: 3 oZ completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
RECEIVED
tact X 7 2021
Information Processing Unit
DWR Section