GW1-2022-06425_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri 4.wARzoNEs
Well Contractor Name FROM TO I DESCRtrn0N
NCWC 4368-A 22 fL 26 it
NC Well Contractor Certification Number
15:ODTERGA3ING for:intiltl cared wells OR LINER da 'lieahte
Maupin Well Drilling FROM To DIAMETER ULiF - MATERIAL
t IL 22 H. W= live
Comparry Name -I&D NER CASING OR 1tIBING dosed=lop
L Well Construction Permit#:302609 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits li.e.UIC,County,State,Variance,etc.) fL & tn.
3.Well Use(check well use): & f, in
Water Supply Well: :17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural 13MunicipaVPublic 22 IL 26 ft. 4• in. 010 sawn pvc
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R f- in
Industrial/Commercial 13Rcsidential Water Supply(shared)
1tt.GROITf
Irri On FROM 1 TO MATERIAL ' MISPLACEMENT METHOD t AMOUNT
Non-Water Supply Well: I R 22 fL hoteplug Gravity
Monitoring Recovery
—I
ection Well: —— ft. tt
Aquifer Recharge Groundwater Remediation
Y9.9ANDIGRAVELPACK d
Aquifer Storage and Recovery Salinity Barrier FROM TO MA'rnarer. EMPI ACE NEIVT METHOD
Aquifer Test OStormwaterDrainage 22 H- 28 fL to gravtty -
Experimental Technology Subsidence Control R H
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets H netess8
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRFMON tailor,hmda sonimck type,grain size,etc.
I it. : 2 IL brown day
4.Date Well(s)Completed:28 June 22 Well ID# 2 fL 28 it. yellow sand
R.
Sa.Well Location: Ill. � � e
Dora Scott tt. e. ��96 D
Facility/Owner Name Facility ID#(if applicable) H. It.
153 Solo Lane,Knotts Island 27950 ft. H. 3 2022
Physical Address,City,and Zip ft. f,
r g Unit
Currituck 0076000108DO000 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
('dwell field,one hlt/long is sufficient) 22.Certification:
36.52196 N -75.91249
6.h(are)the well(s)OPermanent or Temporary gnuWell Contra Date
7.Is this a repair to an exists well Yes or No with r15AnNCAC 02C.0100 or ISA C C 2C 0l100 w
aids(w&e)coaWtOW-h accordance---- _..--- - ------
• p existing B � Well Construction Standards and that a
If this is a repair,fill out(mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well detalls:
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-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28 (�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd&rent(example-3Q200'and 2(Qa 100)
construction to the following.
10.Static water level below to of 1
P easing: (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. 7 7/8 (in.) 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
(Le.auger,rotary,cattle,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13s.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'of this form within 30 days of
13b.Disinfection type: Hypochrite Amount: s oz 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

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