GW1-2022-00265_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only-
I.-Well Contractor Information:
JOHN PAUL SIMPSON '
ta.�•waTER:zoxes x .S ,t:�x.u, ..�„
\Yell Contractor Name FRO\I TO DESCRWTION
2930—A 21 fL 24 #2 COURSE LIGHT BROWN SAND
ft. M
NC Well Contractor Certification Number [SiU1JTER;[FASING(rti'rnuiultr.:eased-tiretL4,UR<L[NER iC
J P ENTERPRISE FROM '__ Dt.U1WrEn ` 1 Tit CICNESS I MATERIAL
Company Name +1 ft. 121 it 2 I; t° SDR21 JPVC
ARHS 380164 ,16=.1�I,�ER;C�,SINGORT[lgWG theiiiaVd&ed4boV)
2.Well Construction Permit ft FROM TO DIAMMER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIG Count);State,Variance,etc) R M io
3.Well Use(check weU use): ft- ft. in.
Water Supply Well:
FRO\I TO DIAMETER I SLOT SIZE I TffiClO'FSS J DLITERIAL L
❑Agriculnnal ❑Municipal/Public 21 ft- 124 fL 2 1° .010 SCH40 PVC
❑Geothermal(Heating/Cooting Supply) GResidential Water Supply(single) 21 ;n-
❑IndustriaUCommercial ❑Residential Water Supply(shared) .Yn.
❑irrigation oWells>10%000 GPD FROd1 TO V AUTIMILLG E11PIUCENUM It THOD&AY70UNT
Non-WaterSupp►v Well: 0 iL 20 ft• 3/8holeplugGRAVITY
❑Monitoring ❑Recovery rt. fL BENTONITE
Injection Well:
[L ft:
❑Aquifer Recharge ❑Groundwater Remediatian
14'''St1�iD/GR1V1P.i1Cri(if>i ' cable)- > v_^ ,;' ,a '==t,zc
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StoamaterDrainage 20 rL 24 fL #2 SAND; GRAVITY
❑Experimental Technology ❑Subsidence Control 1t• f4
❑Geothermal(Closed Loop) ❑Tracer 10'sDRtlII1CGL'f)G irachadarnonnlsheersRiiecessa }"`
❑Gcothermal(Tlcating(Cooling Return) ❑Other(explain under!I Remarks) FROM TO DESCRIPTION(color:hardness•soiltroek type. min site,etc.) y
0 iL 12 fL DARK BROWN SAND
4.Date WeU(s)Completed: 12/16/2022 Wen ID#380164 12 iL 19 fL BROWN SAND
5a.Well Location: 19 iL 24 fL LIGHT BROWN SAND
NANCY HOUGH % it-
Facility/Owner Nam Fanl"rt-ID#(ifapplicable) % % � g
106 BENJAMiN CT % fL V Ff- 2 9,
Physical Address,Ciry,and Zip ft. it ,. > c�
1)
CURRITUCK 108B00000240000 2t> ►raRKS:T, nit
rr _
County ParceT Identification No.(PIN} 2ND WELL DRILLED AS PER 6 TOMER
5b.Latitude and longitude in degreestminutestseconds or decimal degrees: RELOCATE FOR FUTURE GARAGE
(ifweU field,one latflong is sufficient) Certifieatig
361406 N 75 52 11 W (\` •I 12/16/2022
6.1s(are)thewell(s): nPermanent or ❑Temporary ofCerdfi Well Contractor Date
By 1V'*s f'--1 hernhy certify that tlfe Hrll(s)nns(it-ere)constructed in accordance with
LINO
7.Ts this a repair to an existing weU: ❑Yes or NO 15A B C 02C.0100 or 15.4 A'CAC 026.0200 Well Conmuction Standards and that a copy
jddss is a repair,fell aid known well construction injmmation and erplain the nature ajthe of this record ltas beenprovided to the ne/1 tntnar.
repair under#21 rentarks.section or on the back of this farm
23.Site diagram or additional weU'detaUs:
8.For GeoprobelDPT 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-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: S
24.SUBMITTAL iNSTRUCTiONS
9.Total well depth below land surface:24 Submit this GW-1 within 30 days of weU completion per the following:
For multiple wells list all deptks ijdifferent(erantple-3@200'and 2@MY)
♦6 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,IBC 27699-1617
Ijwaterlecet is above casing use
11.Borehole diameter.6 on.) Program,
For Injection Wells:Copy to IDWR,Underground Trajection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:MUD ROTARY 2qG For Water Supply and Open-L..' Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push etc.) county environmental health departne it of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over 100,000 GPD:Copy to D WR,CCPCUA
13a.Yield(913111)30 1VIemDd of test:PUMP
Permit Program,1611 MSC,Raleigh NC 27699-I611
13b.Disinfection type:73% HTH Amount: 1-5 OZ
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