GW1-2022-03739_Well Construction - GW1_20220406

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
GW 1-2022-03739
Are you submitting a scanned form?* Yes
• No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
CHARLES DOZIER, II"BO" [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4088 A CHARLES DOZIER, II TOANO WELL AND PUMP SERVICE,
INC.
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Non-Water Supply Well* Monitoring
Recovery
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
3/8/2022 MAPLE#2 (gallons per minute)"
5.Well Location

Facility/Owner Name* Facility ID#
CURRITUCK COUNTY MAPLE#2
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Currituck
Physical Address* Street Address
AIRPORT ROAD
Address Line 2
AVATION PARKWAY
City State/Province/Region
MAPLE NORTH CAROLINA
Postal/Zip Code Country
27956 UNITED STATES
Latitude* 36.3954000000 Longitude*75.9998000000
Decimal degrees Decimal degrees
........................................................................... ................................................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.)
30 9a.What is the depth of the casing from ground
surface?
For multiple wells list all depths if different
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 10
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
14.WATER BEARING/FRACTURE ZONES
From To Description
15 25 GRAY SAND AND SHELLS
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 15.00 4.50 SDR 17 PVC
in feet in feet in inches

17.SCREEN
From To Diameter Thickness Material
15.00 25.00 4.00 .020 SCH 40 STAINLESS
in feet in feet in inches STEEL
18.GROUT
........ ......... ......... ....... ......... .......
From To Material Emplacment Method&Amount
10.00 0.00 BENTONITE PUMPED FROM BOTTOM TO TOP WITH TRIMMIE
in feet in feet PIPE
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
30.00 10.00 SILICIA#3 PUMPED FROM BOTTOM TO TOP WITH
in feet in feet TRIMMIE PIPE
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 20.00 TAN SAND
in feet in feet
20.00 30.00 GRAY SAND/SHELL MIX
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
.............................................. .....................................................................
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
Signature of Certified Well Contractor