GW1-2022-06795_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON
14::yVATER•NZONES
]FROM TO DESCRIPTION
Ne1lContractorName 115 it, 125 R LIGHTIGREY SAND.
2930-A ft.
NC Well Contractor Certification Number .'t5.,0UTER CASING:formtilh�ased=wells'ORa iNER'if a'"hcable ,
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 1115 ft- 1.25 ! SDR-21 PVC
Company Name
360331 f6 il�nvERCAStNGORTMFNG�(eothirinal"closeit-ioa
2.Well Construction Permit#: FROM TO DIAMETER THICRNE&S EIATERLIL
List all applicable well construction permits(.e.UIC County;State,Variance,etc) ft.
3.Well Use(check well use): ft ft. in.
Water Supply Well: I'TS(:ItEEbl.
FROM TO DTAIIIETERI SLOT STlE TffiCIO-ESS� M.�TER7AI,��
❑Agricultural ❑Municipal/Public 115 ft- 125 fL 1.25 in.i: .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) fG 1115 ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18' i2QUTv .�0krigation ❑Wells>100,000GPD FROM TO MATERLAL E\IPLIC&\IENTMETHOD&AMOUNT
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- -- Non-Water Supply-Well: —" - - 0 ft 20 ft_ 3/8 holeplug GRAVITY -~
❑Monitoring ❑Recovery it ft. BENTONITE
Injection Well:
It. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19.".SANDIGRAVLLIPACK'da"livable) .-,
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormtrnterDrainage 20 ft 125 ft, #2 SAND IGRAVITY
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 30.}DRUTANGLOG,fattaetindditt8unlsheetsifuecessa t,= ' r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardne soil/rock •w size etc.)
0 ft, 25 ft. BROWN;SAND
4.Date Well(s)Completed: 6-6-2022 wen 1D#360331 25 ft• 40 ft- LIGHT BROWN SAND/GREY SAND
5a.Well Location: 40 ft• 65 ft- GREY;SAND SHELL SPECS COURSE
RICHARD ROSE 65 fL 95 rt• CLAY,FINE GREY SAND,SHELL SPECS
Facility/Owner Name Facility ID#(ifapplicable) 95 fti 110 ft CLAY.;FINE GREY SAND
106 GOLDEN JUBILEE ST 110 ft 125 ft• LIGHT�G,REY SAND 1A
Physical Address,City,and Zip ft. ft. k_
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CURRITUCK 11 OA00400160000
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County Parcel Identification No.(PIN) JUL 1
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rzaf -'t
(ifwell field,one Iat/long is sufficient) 22.Certification: ' $���•!G UNIj
36 10 05 N 75 51 39 �� I; on7v'a'�c<�O,�ac�
6/6/2022
6.Is(are)the well(s): nPermanent or ❑Temporary Si a of Certified Well Contras or Date
- — By ing this farm,I hereby certify that thew•ell(c)war(here)conctrurted in accordance with
7.is this a repair to an existing well: ❑Yes or MNI o 15A CAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis it a repair fill out known well construction iurormadon and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this farm.
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.SUBNN TTTAL INSTRUCTIONS
9.Total well depth below land surface: 125 (ft.) I'
For multiple xe/ic list all depths if different(ecartr/tle-3@200'mui 2Qa IOD) Submit this GW-1 within 30 days of well completion per the following:
-}6 24a. For All Wells: Original fo I to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,rise••+•• 1
11.Borehole diameter:6 (in.) 24b.For Injection Wells:Copy toi DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M U D ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.augger,rotary,cable,direct push,etc.) county environmental health departme it of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Ivelr 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm)`�O Method of test: PU M �
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/3b.Disinfection type: 73% HTH Amount. 2.0 OZ �
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