GW1-2022-08250_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 1a.WATER ZONES
:.
Well Contractor Name FROM TO DESCRIPTION
2930-A 20 R 25 fL LIGHT BROWN SAND
NC Well Contractor Certification Number 15.'OUTER CASING for molt eased;i ells ORLINER if a`7icabl'
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
+2 fL 20 rt 2 in SDR21 JPVC
Company Name
ARHS 364802 16-INNERCASINGORT[1BING eothermalclosed-loo -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well:
FROM TO DIAMETERSLOT SUM I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Pubhc 20 fL 25 'L 2 in. .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) fL 20 ft- is
❑Industrial/Commercial ❑Residential Water Supply(shared) Ig;GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n' 20 ft. 3/8 hole plug GRAVITY
❑Monitoring ❑Recovery R. ft. BENTONITE
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVELPACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
[]Aquifer Test ❑StormwaterDrainage 20 tt 25 n #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer -10.DRELLINGI OG attach additionalshects if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock in dw,etc
0 rt. 10 ft FINE SAND CLAY
4.Date Well(s)Completed: 3/30/2022 wet,ID#364802 10 fL 25 rt LIGHT BROWN SAND 1 a,2
5a.Well Location: H. R f
PATRICK GILMER FORBIS rt. rL
Facility/Owner Name Facility ID#(if applicable) ft. It
108 PARKERS LANDING DR POINT HARBOR NC 27964 ft. It.
Physical Address,City,and Zip ft. fL Dm
CURRITUCK 132F00000370000 Zl.4 MARKS
County Parcel Identification No.(PIN) SEPTIC NOT INSTALLED AT TIME OF DRILL SERVICE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) a 'frcatio Q
36 05 12 N 75 47 59 w - 3/30/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Si o Certified Ati Contractor Date
knf
By 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: ❑Yes or 8No 15A CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 this form. 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 r@200'and 2@100)
10.Static water level below top of casing: +6 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) Program,
For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: P U M P Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018