GW1-2022-00269_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHN PAUL SIMPSON
\Nell Contractor Name FROM TO DESCRUMON
2930-A 33 rL 37 LIGHT COURSE GREY SAND
fL ft I
NC Well Contractor Certification Number ;it$;Oi]7 ER;CaSiNt for."m61ti cased Pelts`OR-LT\Eit'iDa""Leable `_`<z
J P ENTERPRISE mn't I To DIAMETM MATERIAL
Company Name +3 fL 33 a. 1.25 i SCH21 JPVC
TDPJiERCASiRiGOR,TUBtNC 'eottiermb!'etosed-loo �ii
2.Well Construction Permit#: NA Mail TO MAIM'= THICI NU&S MATERIAL
List all applicable w/7 construction permits(Le TWC,Como;State,Variance,etc) n- ft. in.
3.Well Use(check well use): ft ft. ra
Water Supply Well: ,IV-SCREEN
FROM TO DIAMORMIt I SLOTSIZE I T11100,TM ,LkTKRIAL
❑Agricultural ❑MunicipaitPublic 33 ft. 37 It. 1.25 'n- .010 SCH40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL 33 fL
❑Industrial/Commercial ❑Residential Water Supply(Shared) ''l$3"GROUT.
Qlrrigation ❑Wells>100,000 GPD FROM TO~ MATERIAL LltPLtCEMENT 1'%WrHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 1 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. rL BENTONITE
Injection Well: ft- ft.
❑Aquifer Recharge ❑GroundRater Remediation
_19?%SAA'1)!l;li1VTI PACKaa licalile) { Fu .,.,3
❑Aquifer Storage and Recovery ❑SalinityBarrier FRall TO MATERIAL EMPLACEarENTMETHOD
❑Aquifer Test ❑StormmaterDrainage 20 re 37 it• #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control 1L fL
❑Geothermal(Closed Loop) ❑Tracer ;20 DftfL>Vfi�G1 OG(atmcti'fiddmo�iils6eetcif" ti`=`"<,.t,,»'=. h'
❑Geothermal(IleatingtCooling Rctum) ❑Other(otpiain under#21 Remarks) FROM TO D&SCRIPITON(color,hatdnem soiltrock a sirs,etc.
0 & 23 ft- BROWN SAND CLAY
4.Date Well(s)Completed: 11i10\2022 wenW# 23 FL 30 IL GREY SAND CLAY
5a.Well Location: 30 ft: 40 LIGHT:GREY SAND
FORREST TUCKER ROSE It. ' "tz-L.A
Facility/OwnerNamc FacilRyW#(ifagplicable) fL fL
370 GRANDY BACK RD ft. ft. _
Physical Address,City,and Zip ft. f6 '9 UnitCURRITUCK 00950000390000
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestminutestseconds or decimal degrees:
(if we0 field,one lat/long is sufficient) 22-Certification: '
36 13 35 N 75 53 14 W - 11/10/2022
6.is(are)the well(s): ❑Permanent or OTemporary Si ure of Cenified w onuac r !, Date
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Bysigaingthisform•I hereby certify that the we/l(s)not(were)constricted in accordance with
7.is this a repair to an existing well: ❑Yes or ©No 1 SA NCAC 02C.0100 or 154 VCAC 02C.0100 Well Catutraction Standards and that a copy
lfthis is a repair,fill out lormvn will construction information and erplain the nature ofthe ofthis record Iras been provided to the it-ell onder.
repair tinder il21 rewadcs section or on the back of thisfoim.
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:37 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells/itt all depths if different(eranrple-3 aG1 t00'and 2Q1Off) y n p
10.Static water level below top of casing: +6 (fL) Information
For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing rise"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter••6 (in-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(L.Well construction method:MUD ROTARY 24c.For Water Supply and Open-Ldop Geothermal Return Wells:Copy to the
e.auger,rotary,cable direct posh etc.) county environmental health departocht of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,060 GPD:Copy to DWR,CCPCUA
13a.Yield Ggpm)20 Method of test:PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:73% HTH AmDunt:2.0 OZ
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