GW1-2022-06904_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON
Well ConlractorName FROM TO I DESCRIPTION
2930=A 21 it- 25 R BROWN SAND
it. ft.
NC Well Contractor Certification Number 't5:i0VMRCASING.ror.Illulti4aiid'wells OR'LINER ifahcable
J P ENTERPRISE F'ROM1 TO DTAMTErER T}IiCIINESS AiATERTaL
+1 fL 21 fr. 2 in. SDR21 JPVC
Company Name ;,_t6:`INNRR CAS C OR T[JBING'( 'ottiecmal;ctoseilaoo a.M
2.Well Construction Permit#• FROM To DIAMETER THICKNESS I MATERTAL
R.
List all applicable well construction permits d.e UIC,Coenrt5;State,Variance.etc.) ft. ;
3.Well Use(check well use): it f, ,rn'
1TSCREEN
Water$nPP1Y Well: ��_
FROMI TO DIAMETER I SLOT SIZE TIHCIC�'ESS AL-VTERIAL r•
❑Agricultural ❑Municipal/Public 21 il• 25 it 12 " 1010 ISCH40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) g• 21 f in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) ;t8:'GROT)T�u y`+.,<ap s .,}. d;x�.. .,a's .,•r<:.;, �G=:
Ohrigation ❑W ells>100,000 GPD FROM TO MIATERiAL EMIPLICEMENT A[EPHOD&AMOUNT
Non-Water Supply Well: _ - —- -- - -- -_ 0 - #- 20—-- ft--3/8 holeplug GRAVITY 200 LB
❑Monitoring ❑Recovery, ft. n• BRNTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge []Groundwater Remediation
AWSAND/GRAVEUTACIC(if,a plicalile)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EM PLACEMENT METHOD V
[]Aquifer Test ❑StormwaterDrainage 20 it• 25 it• #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control n• ft. 14-50LB BG
❑Geothermal(Closed Loop) ❑Tracer "20 DR11 MG:LUG attach additional'sheefs if oecessa )„y "
❑Geothermal FROM TO DESCRIPTION'(eotor,hardness.soi0rockt a size,etc.)4
(Flcating/Cooling Return) ❑Other(explain under#21 Remarks)
0 n 10 it• BROWN SAND
4.Date Well(s)Completed: 5/18/22 Well ID# 10 it• 25 it• BROWN SAND
5a.Well Location:., ft. ft.
fL ft. 'Y-E n it rn '
CHRISTOPHER EAST F
Facility/OwuorNamc Facility lD#(if applicable) ft. ft. -
176.N SPOT. RD % `
Physical Address,City,and Zip fL i1'
CURRITUCK 01230000890000
21 REl<tARKS! .: ..` Ikv!'; K. ";'r s1111f l ,... :•:'+;-:
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County Parcel identification No.(I'M
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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(if well field,one la(/long is sufficient) Ce tification•
36 07 40 N 75 49 50 W !I • 5/18/2022
6.is(are)the well(s): ❑permanent or ❑Temporary Si tore of Cenifi We 1 Conuac r Date
- - B' i Wing this form,I hereby certify that the aell(.c)was(were)constructed in accordance with-
7.is this a repair to an existing well: ❑Yes or ItNo 15 ,CAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
#'this is a repair;fill out known well construction h formation and explain the nature of the of this record has been provided to the well oamer.
repair tinder#21 remarks section or on the back of this farm
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal}Veils 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:25 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple well;list all depths iil'dierent(example-3@200'and 2@1001 I
+5 FT 24a• For All Wells: Original form to Division of Water Resources (DWR),
.u Static water 1 e ca]below top of casing: (H•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If uwter lcn�el is above casiirg;rise"+" �
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole_diameter: (in.) I
Program,1636 MSC,Raleigh,NC 27699-:1636
12.Well construction method: MUD ROTARY 2,1c•For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.'auger,iotary,cable,direct push•etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over f00,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)30 Method of test: PUMP Permit Program 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 73/o HTH Amount: 1.5
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