GW1-2022-08261_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel Veltri to aATERizONES' 1 k:
Well Contractor Name FROM TO DESCRIPTION
NCWC 4368A 32 H• 47
R R
NC Well Contractor Certification Number JS OUTER'CASMG'fofm6ltidxsedwefts ORLINEtt Sa`"'livable
Maupin Well Drilling FROM I TO DIAMETER THICKNM MATERIAL
1 fL 37 H- 1 114 in. sch-0U pvc
Company Name 96.INNMC-ASING OR TUBING: the mid eloaeba
2.Well Construction Permit#:367666 FROM I TO I DIAMETER I TRICKNEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance etc.) R R I in.
3.Well Use(check well use): R R in.
;17:SG1tEEN t.a.•r;'. , ? _ x c
Water Supply Well: FROM I TODIAMETER I SLOT SIZE 4 THICKNESS MATERIAL
_ Agricultural E)Municipal/Public 37 R 47 R 1114 1O .010 sdr40 pvc
Geothermal(Heating/Coohng Supply) Residential Water Supply(single)
ft. IL in.
Industrial/Commercial E)Residential Water Supply(shared) ;18 GROUT,ar
_ T,
71brigation FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 R 36 R Holeplug Gravity
[Aquifer
itoring Recovery ft. R
ion Well: R R
ifer Recharge Groundwater Remediation
.s19:SAND/GRA�'EL''PACK a bcable.>,; rc�,
Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEN rMETHOD
ifer Test 13Stormwater Drainage 37 ft- 47 R 1Asand gravity
erimental Technology Subsidence Control lit. R
thermal(Closed Loop) Tracer ',20sDRILLIIVGI oG attaeliadditlonalsheets if tithermal(Heatiug/Coolin Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color hardness,salbrmck in sane etc
1 n- a R gray day
4.Date Well(s)Completed:8 April 22 Well ID# 4 n• 12 h yellow sand
5a.Well Location: 12 H 14 rt peat moss
Thomas Blanton 14 a. 16 R Tree
Facility/OwnerName Facility ID#(ifapphcable) 16 H H day
106 Raccoon dr Knotts Island 27950 30 "' 32 ft.Physical Address,City,and Zip 32 ft. 47 R gray sand
C muck 07 �6A0000020000P�) -21.,RFMARKS `> ` z 202?
Parcel
tion No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient)
22.C 'reatlo . �i, :..' •'��Gti'a����vC��'�re-�'.�t`3
36.53427440 N -75.92685570
1 c 2Z
6.Is(are)the well(s)OPermanent or 13Temporary of Cettdied Date
By signing this form,I hereby—tfv that the nr11(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Ves or EjNo with 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
f 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 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 site details or well
construction,only 1 GW-1 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: 47 (R) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffarw(example-3Q200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:12 (ft.) Division of Water Resources,Information Processing Unit,
If outer level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
,,.Borehole diameter.4 7/8 (in.) 24b.For Iniection Wells: In addition to sendingithe form to the address in 24a
12.Well construction method:
mud rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,mtary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,lNC 27699-1636
i
13s.Yield(gpm) 20 Method of test- pacer pump 24c.For Water Supply&(niection Wells: In addition to sending the form to
the address(es) above, also submit one copy ofthis form within 30 days of
13b.Disinfection type: hyopchrite Amount: 3 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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