GW1-2021-00374_Well Construction - GW1_20211228

WELL CONSTRUCTION RECORD(GW-1? For Internal use only:
1.Well Contactor lnformatlon:
Daniel C.Veltri j 14,WATER ZONES+ ,
Well Contractor Name FROM TO I DFSOtIMON��
55 ft- 75 ft. p.,an
NCWC 4368-A
NC Well CorunitorCatifintionNumber 15007)rRCib7NG mollFeaieii'wtna'OR'IINILR Ya
Maupin Well Drilling LLC FROM TO DIAMEIFB TMCRNFSs MATERIAL
fL 165 ft 1 2 in. Isdu40 live
Company Name
1ti;INNERCASiNC`ORTITBINC ` ' eloseda
2.Well Construction Permit#:270179 FROM TO DIAMEM TmCtnIWM MATERIAL
list a/1 applicable well construction permits r e.U1C.Counly,&ate,Variance.etc.) ft. ft.
3.Well Use(check well use): ft' ft. 1O
water Supply well: 7.SCREEN
- FROM I TO I tAMEWR SLOT suz TmCENM MATERIAL
Agricultural 3Mtmicipal/Pub6c fL 15 & 2 1° o.ot0 sdrdo pvc
Geothermal(Heating/Cooling Supply) 131kesidential Water Supply(single) ft, f, to
Industrial/Commercial Residential Water Supply(shared) 1&GRODT .Irrigation FROM TO MATERW. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welk t ft sa iL hdeptu9 9—ity
Monitoring DRecovery ft. ft.
Injection Well: fL fL
Aquifer Recharge DGroundwater Remediation
A9:SANIK RAVEL,
PACK MATERIALk ;a
Aquifer Storage and Recovery DSalmlty BaBarrierr FROM TO EMPLACEMENT METHOD
Aquifer Test 13StormwaterDrainage 65 ft. 75 ft. DSI Graft
Experimental Technology Subsidence control ft
Geothermal(Closed Loop) 13Tracer 2k l) LING L0r-attach additional abeefrif tteuaria .`
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) FROM To DESCRWnON Dolor,herdn I ft&eaivroek a. cte
t ft. a f4 gray clay
4.Date Well(s)Completed:16 Dec 21 Well D)# a ft. 20 ft. ti�Y ate &an
Sa.Well Location: m 28 ft fidal Snell -° ��•.
Steve Reed 28 R 55 ft. day and an mad Q rt^rr
Facility/Owner Name Facility ID#(ifapplieable) 55 ft. ra ft. W"sand O L(�L
200 Sorrel Ln Moyock 27958 re. n
Physical Address,City,and Zip ft. ft. �
Currituck 032A00000100000 21.REMARKS w�Mv�JvO
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslmfnutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22. on:
36.43994 N -76.08781
17 Dec 21
6.Is(are)the well(90eesmaneat or [3Temporavy S, Well Date
B v signing this form,I herby certify that the weU(s)was(were)constructed in accordance
7.is Wis a repair to an existing well: FaYes or [3No with 15A NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Cansuumion&=dards and that a
/f this is a repair.fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the bock of this form.
E3.Site diagram or additional well details:
8.For GeoprobeMPT or Clrued-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed indicate TOTAL NUMBER of wells construction details. You may also attach additional'pages if necessary.
drilled SUBMMAI,U 'RUCTIONS
9.Total well depth below land surface: 75 00 24a.For All Wells: Submit this form within 30 days of completion of well
For mutripk wells list ail depths ifdiiffow t(example-3@200 and 2@1003 construction to the following:
10.Static water level below top of casing:6 00 Division of Water Resources,laforutation Processing Unit,
ffwater level is above casing,use"+^ - 1617 Mail Service Center,Raleigh,NC 27699-1611
11.Borehole diameter. 5 718 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
12 wen construction method Mud Rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le-mrges,rotary;mbk+;dw-posh;-etc
:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 20 Method of test pacer pump 24c.For Water Supply&Injection Wells: In addition to sending the form to
Hypoclirofte 4 oz
the addresses) above, also submit one copy of this form within 30 days o
pe: f
13b.Disinfection ty Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

_.. _ _. __
�::�-
..:
�Z
.�.. . ,
. a,