GW1-2022-00258_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
JOHN PAUL SiMPSON
Well Contractor Name FROM TO DESCRUMON I
2930-A 63 iG 67 R LIGHT GREY COUSE SAND
NC Well Contractor Certification.Number :t&5 01YFER':Ct1StNG fo"rvinlh cased'.welts'OR L'iNER"tea'`"`beable;?'•
J P ENTERPRISE FR031 TO DL1AIEfERV THICKNESS MATERIAL
+1 fl. 63 ft 11.25 1 SDR21 JPVC
Company Name
365089 "rfr:iNNERCASiNG:OR';Ta11iNC eothermul closeddoo ;
2.Well Construction Permit# LIA FROM TO DISIER., THICIGMSS I MATERIAL
List all applicable well construction permits(i.e.WC,County,State,irariance,etc) ft. R- in.
3.Well Use(check well use): fL fL
17.''SCREEN•
Water Supply Well: FROM TO MMEIER SLOTSi7.E TMCIL-;ESS MATERIAL "L
❑Agricultural ❑MtlnicipalJPublic 63 ft- 67 fL 1.25 '010 SCH40 JPVC
❑Geothermal(Heating/Cooling Supply) !°!Residential Water Supply(single) ft- 63 fL in,
❑Industrial/Commercial ❑Residential Water Supply(shared) L8s'CRODT.�,
❑hTigation ❑Wells>100,000GPD FROM TO MATERIAL.;' L%tPLACFAlFNrTWTHOD8N1tOUNT
Non-Water Supply Well: 0 n 20 fL 318 holeplug GRAVITY
❑Monitoring ❑Recovery ft. n• BENTONfTE
Injection Well: ft. EL
❑Aquifer Recharge ❑Groundwater Remediation
19:S:�'DIGR�l'fTEL'Pr1GK'ri'a plieable) .,` ,,,:x.• ".,',,. 'c, «,, ,_ ...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROII TO MATERIALI. I FAIPLACEMENTMETHOD
❑Aquifer Test ❑StormrvaterDrainage 20 iL 67 iL #2 SAND 1GRAVITY
❑Experimental Technology ❑Subsidence Control & N-
❑Geothermal(Closed Loop) ❑Tracer 20 DR11i11i\Gi"Cot uehaddiiionuisheetiif;uecessa t"
❑Geothermal(Rciting/Cooling Return) ❑Other(explain under, I Remarks) FR031 TO DESCRIPTION(color.hardness,soiUrocA type,main Sire,etc.)
0 ft 13 it CLAY BROWN SAND
4.Date Well(s)Completed: 10/4/22 , 365089 13 it 45 it FINE GREY SAND
5a.Well Location: 45 tt. 55 fL DARK GREY SAND SHELL SPECS
JESSICA MCHONE 55 %- 67 'i• LIGHT GREY SAND COURSE
Facility/OwncrName Facility IW(tfapplicable) iL f
254 BOUBON ST CAMDEN 27921 ft. it.
Physical Address,City,and Zip ft. fL [
CAMDEN 028937004096660 t21:REi1I�RK5,,s_Ft,t ., .,
County Parcel ldentification No.(PiN) li `^ ^t'-�1 Prrc3o,!*za UrVA
5b.Latitude and longitude in degrees/niinutestseconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 22 r6fcation:
36 23 05 N 76 09 49 W
''- 10/4/2022
6.is(are)the well(s): ❑Permanent or ❑Temporary Signal ofCenified W Contractor ;' Date
Bpsi rt thisfnrm,I hereby certify that the uell(s)uns(uere)constructed in accordance Will
7.is this a repair to an existing well: ❑Yes or 11No ISA NCAC 02C.0100 or 15"1 NCAC 02C.b200 Well Construction Standards and that a copy
jthis is a repair,fill out humvtt well construction information and explain the nature of the of this record has been provided to the nvii'aumer
repair tinder#21 remarkT 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 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:67 (ft.) i'
For multiple wells list all depths ii'different(example-3Qa 200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casin • +6 (ft) 24a. For All Wells: Original fotml to Division of Water Resources (DWR),
If rater level is above casing.use"+ g• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
f11
11.Borehole diameter 6 (in,) tab.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
MU D ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12 Well construction method: 24c.For Water Supply and Operl-loop Geothermal Return Wells:Copy to the
(Le.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)20 Method of test:PUMP
Permit Pragram,1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: 73% HTH Anwunt: 1-5 OZ