GW1-2022-09300_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor l nfornmtion:
Daniel C.VeM la wArERzoNEs
Well Contractor Name FROM I TO DESCRIPTION
NCWC 4368-A 4 ft 1e fl-
46 ff sa IL W.,
NC Well Contractor Certification Number ]&:OUTER CASING for.iaolfi¢aced`welt OR LINER'd ffewo
Maupin Well Drilling LLC FROM I To DIAMETER TFIICRNESS MATERIAL4
1 ft- 1 47 ft- 1114 1- sdr-21 pvc
Company Name
333512 =INNER CASING,OR TUBt1IG ' t i No aaen
16
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERrnL
List all applicable weB construction permits r.e UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft % 1a
Water Supply Well: 47.SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 47 ft 1 57 fL 11/4 ro• .010 sch40 pvc
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. & in
IndustriallCommercial EBResidential Water Supply(shared)
1&GIROUT
Irrigation FROM I TO., MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft- 48 ft Holeplug gravity
Monitoring DRecovery, ft. ft.
Injection Well:
R
Aquifer Recharge [3Groundwater Remediation 19. R.
SAND/GRAVEI PACK 's' ticable
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL- EMPLACEMEM METHOD
Aquifer Test 13Stormwater Drainage 47 ft- 57 ft- dsi gravel 1A gravity
Experimental Technology 13Subsidencc Control ft. ft.
Geothermal(closed Loop) 13Tracer 30.DRILtING'LOG attach additioaal;sheels if Asa ,
Geothermal(HeatingtCooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardnesk soiurock type,gmin dze,etc
I H- 4 rL brown day
4.Date Well(s)Completed:13 Sept 22 Well ID# 4 fL 1, % yellow sand
Sit.Well Location: 1e tL 20 ft. peat cross t...e -
David Newnam 20 fL 46 IL gray day
Facility/(honer Name Facility ID#(if applicable) 46 ft. ft Gray sand
139 West Blackfoot,Knotts Island. 27950 f4 ft Liri
Physical Address,City,and Zip ff• it•
Currituck 007700022A0000 .21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field onelat/loag is sufficient) eriifIca o .
36.50325 N -75.92863 A
14 Sept 22
6.[s(are)the weti(s)OPermanent or 13Tempormy fure4eCertified Well Contractor Date
By signing this form,I hereby terrify that the wells)was(woe)constructed in accordance
7.h this a repair to an existing well: [3Yes or [3No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair full out drown well construction it formation and explain the nature of the copy ofdas record has been provided to the well inner.
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.
hued' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 57 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200 and 2@100) construction to the following:
It Static water level below top of casing:10, (fL) 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-4 7/8 (in-) _24b.For Infection Wefls:_In addition to sending the form to-the address in 24a
mud rotary above,also submit one copy of this form within'30 days of completion of well
12 Well construction method
construction to the following:
(i.c.eager,rotary,cable,direct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 15 Method of test: pacer pump 24c.For Water SuuDly&Infection 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: Hypocrite Amount: 30Z 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

RECEIVED
SEP 2 6 2022
NC DEQ/DVVq
Central Office
�G ;; • • GPI
rh
n
6\