GW1-2022-01127_Well Construction - GW1_20220113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.WATEI:ZONES <;...
Well Contractor Name FROM TO DESCRIPTION
2930-A 70 ft- 80 ft- LIGHT GREY SAND/ SHELL
ft rt
NC Well Contractor Certification Number -45.OUTER CASING for mtilti-casediwells OR'L'1NER if 8 IicaDle
J P ENTERPRISE FROM To DIAMETER THICIQHFSS 1NATERIAL
+1 ft 70 ft 2 ' in SDR21 JPVC
Company Name
#337524 16.INNER CASING OR TUBING eotliernial doseaaao .-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. M In.
17;SCREEN >^ __
Water Supply Well: FROM I TO DIAMEMR f SLOT SIZE THICENESS I -MATERIAL "
❑Agricultural ❑Mumcipal/Pubhc 70 ft 80 fL 2 " .010 SCH40 JPVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft 70 fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery tL. fL BENTONITE
Injection Well:
ft. tt
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK if a "licable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwataDminage 20 ft. 80 ft MAN D GRAVITY
❑Experimental Technology ❑Subsidence Control fL n-
❑Geothermal(Closed Loop) ❑Tracer 20 DRILIANG LOG attach additiotial'sheets if necessa
,0 at(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCREPTION color,baritness,soilf a k qM grain sim,etc.
0 it. 13 rt BROWN SAND
4.Date Well(s)Completed: 11/10/2021 well lD#337524 13 ft- 20 ft. LIGHT BROWN/GREY SAND
5a.Well Location: 20 rL 30 ft- LIGHT GREY/SHELL SAND
CHARLES WILSON 30 lt. 65 IL FINE LIGHT GREY SAND/CLAY
Facility/Owner Name Facility ID#(if applicable) 65 ff 80 ff GREY SAND/. SHELL SPECS
1420 US HWY 17 S,LOT-B(1430)ELIZABETH CITY 27909 rt rt
Physical Address,City,and Zip ft. ft ti
PASQUOTANK NOT Identification
21REMARKS ->= -
County Parcel 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
36 15 22 N 76 18 36 W lr, - UPI
1/6/2022
6.Is(are)the well(s): (tPermanent or ❑Temporary Si of Certifiad Well Contractor Date
By ' ing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy "
Ythis 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: 80 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I001
10.Static water level below top of casing: +6 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (�) 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(TUC)
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 insta ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciuE over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)25 Method of test: P U
Permit Program,1611 MSC,Raleigh,NC 27699-1611
0
13b.Disinfection type:73/o HTH Amount: 1.5 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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