GW1-2021-02805_Well Construction - GW1_20210805

f
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.WATER'ZONES t "
Well Contractor Name FROM TO DESCRIPTION
2930-A 22 fL 27 rL LIGHT BROWN SAND
n ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi ease Wetis OR LINER it 5' livable
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 20 it. 12 i In. SDR 21 JPVC
Company Name -
P# 361467 .16.-INNER CASING OR TUBING eotnermal closeaaoo
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.CAC,County.Slate,Variance,etc) ft. ft. in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22 fL 27 ft. 2 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) g 22 g•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 m 20 R 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery tt• fL BENTONITE
Injection Wet:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Cifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' i EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 fA 25 fL #2 SAND DSI I GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionatsheets If necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain trader#21 Remarks) FROM TO DESCRIPTION color,harde soiltmek a in ' ere.
7/26/2021 361467 0 � 10 � BROWN SAND
4.Date Well(s)Completed: WeB ID# 10 20 BROWN SAND
5a.Well Location: 20 fL 27 fi- LIGHT.BROWN SAND
BRIAN 8r KIMBERLY PARKS ft. fL IN
Facility/Owner Name Facility ID#(if applicable) fL fL
104 BRUCIE CT POINT HARBOR, NC 27964 fL
Physical Address,City,and zip ft. rt.
CURRITUCK 132G0000032000 21.REMARKS OVA
s
County Parcel Identification No.(PIN) 3�10h1 g lOn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 2 Ce 'fication:
i
36544 N 75 48 16 W
6.Is(are)the well(s): OPermonent or ❑Temporary Si—gnalEre of Certified We Contractor Date
By s ing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing Well: MYes or ❑NO I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair fill out brown 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 thisform. 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:27 (ft.)
For multiple wells list all depths if different(example-3@200'and 1@I00) Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: +9 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD 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 producingover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: r—p U M P Pit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type. 73% H T H Amount: 1.5 OZ
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018