GW1-2022-09301_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri t4 WATER ZONES"
FROM TO DESCRIMON
Well Contractor Name
NCWC 4368-A a it- 33 ft. ,� a
rt fl.
NC Well Contractor Certification Number ]5.0UTER CASING for tnulfised wells OR LINER` "livable
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS I MATERIAL
1 ft. 23 R' 11/4 rn' sdr-21 i pvc
ComparryName ,..
363408 :16:ny1veRcasnve;oR.Tm31xG , '_...
2.WeR Construction Permit#: FROM TO - DIAMETER THICKNESS 'MATERIAL
List all applicable well construction permits(Ge UIC,County,State,Variance,etc.) ft. ft. In'
3.Well Use(check well use): ft' ft' im
R 517�+ i
Water Supply Well: F
FROM TO ,.DIAMETER SI.O'r �..T®C[Q7ES5 MATERIAL
Agricultural 13Municipal/Public 73 It. 33 fL 1114 1D o10 sch-40
Pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft % iv
Industrial/Commercial Residential Water Supply(shared) _
,I&GROUT,
litigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water
Supply Well: 1 fL 20 ft Holaplug gravity
Monitoring Recovery ft ft.
I(Goothermal
ection Well: ft R
quifer Recharge Groundwater Rem 19
ediation .SAND/GRAVEL PACK if:si tieable
quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
quifer Test 13Stormwater Drainage 23 ft. 33 ft, dsi gravel 1A gravity
xperimental Technology Subsidence Control ft. ft
eothermal(Closed Loop) Tracer 20.DRTI L INGLOG attach additionalslitits if necessa
(Heating/Cooling Return) rJOther ex lain under#21 Remarks) FROM TO DESCRIPTION color,bardnem,soNrock Mw,grain eta
1 ft. 4 fL broxnday
4.Date Wells Completed:13 Sept 22 Well ID# 4 ft. 33 ft.
() mP yellow sand
5a.Well Location: ft ft
John Parker n
Facility/OwnerName Facility lD#(ifapplicable)
108 Black Bass,Knotts Island. 27950 ft rt
Physical Address,City,and Zip It. I ft ' L'
Currituck 00770000033000 21:REMARKs..'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesi'm nutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .Certification:
36.50875 N -75.91294
4 Sept 22
6.Is(are)the well(s)OPermanent or Temporary ngnature o ntractor Date
By s g this form.I hereby certify that the well(s)ens(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with ISA NCAC 01C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,full out known nell constriction information and erp/ain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#2I 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: 33 wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(crumple-3@200'and 2@I00) construction to the following.
10.Static water level below to 3'
P of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter.4 7/8 (in.) 24b.For Iniection Wells: .in addition to sending the form to the address in 24a
12.well construction memos:
mud rotary above,also submit one copy of this form within'30 days of completion of well
(Le.auger,rotary,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,NC 27699-1636
13s.Yield(gpm) 15 Method of test:pacer pump 24c.For Water Supply&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.
Fomn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
RECEWWEp
SEP 26 2022
NC DEp/DWR
Central Office

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