GW1-2023-01011_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON KWATER-ZONES
FROM TO DESCRIPTION
Well Contractor Name 21 f- 24 #2 COURSE LIGHT BROWN SAND
2930—A RE:( LWED ft.
NC Well Contractor Certification Number
JAN 2 5 2023 I F
J P ENTERPRISE FROM TO DIAMETERTHICKNESS ft.
+1 ft. 2 in- SDR21 PVC
Company Name lrgomriaUan Pracm*q LW 1 1 I , J
"I&INNER CASING Otte
2.Well Construction Permit#:ARHS 38G)V64 DOG FROM TO I DW113TER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),,State,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well.- ,17-,SCREEN
FROM TO DIAMETER! I SLOTSIZE THICW-NESS &LITERIAL
OAgricultural OMunicipal/Public
[]Geothermal(HeatinglCooling Supply) InResidential Water Supply(single) 21 " 24 .010 SCH40 PVC
1 2 1"' 1
ft.
Eliridmtrial/Comm_ercia-I 0 Residential Water Supply(shared)
0irrigation DWells>100,000 GPD FRO151 I TO NIATERML F51PLAtCENIENT 1%W1HOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- 3/8 holeplug GRAVITY
DMonitoring ORecovery rL ft- BENTONITE
Injection Well:
% ft.
0Aquifer'Recharge OGroundwater Rernediation
..SAND/GRAVE K.
ElAquifer Storage and Recovery 0 Salinity Barrier FROM TO LVAC7 EMENTMETHOD
.1. EMPLAC
13Aquifer Test OStormwatcr Drainage 20 1- 24 ft- 1#2 SAND GRAVITY
OExperimental Technology IZISubsidence'Control ft. I ft. I i
ElGeothermal(Closed Loop) OTracer _20.'DR1I1MG!L0G4atiach hdditioriaFgh inieciiii"
—
[]Geothermal(Heating(Cooling Return) -00thcr(explain under#21 Remarks) F*ROM TO DESCRIPTION(color.-hardam soiUre-clitype,pain size,etc.)
0 fL 12 DARK IBROWN'SAND
'
4.Date Wells)Completed: 12/16/2022 -WcnID080164 12' 19 BROWN'SAND,
Sa.Well Location: 1'9 fL 24 ft- LIGHT BROWN SAND
fL.
.NANCY HOUGH . - - ­ ft :
Facility/Owncr Name Facility M#(if applicable) ft. ft
106 BENJAMIN CT ft. ft.
Physical Address,City,and Zip ft. ft.
CURRITUCK 108B00000240000 �21.,REMARKS
County Parcel Identification No.(PIN) 2ND WELL DRILLED AS PER CUSTOMER
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: RELOCATE FOR FUTURE GARAGE
(if well field,one lattiong is sufficient) Certifead
36 14 06 N 75 52 11 W 12/16/2022
6.ls(are)thewell(s): nPermanent or OTemporary
Si A of Certifie Well Contractor Date
Bps it ng this farm 4 lherrhy certify that thewell(q)ivas(were)cointructedin accordance with
7.Is this a repair to an existingwell: ElVes or 8No 15A C 02C.0100 or 15.4 JVCAC 02C.0200 Well Construction Standards and that a copy
]this is a repair,fill out butim well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or-on the back of this form 23.Site diagram or additional wellidetails:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yol';.'may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:24
For multiple wells list all depdzs,if different(erampIk-3@200'cord 2@101y). V0 Submit this GW-1 within 30 days o f well completion per the following:
+6 24a. For.All Wells!"On-' I form to Division of-Water.Resources (DWR),
. Unit,
orin .
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Vrwater leiii is ab6ve'casing.use
6 24b.For Injection-Wells:!Copy to DWI;,Underground Injection Control(IUC)
I.I.-Borehole diameter: Program,1636 MSC�,Raleigh.;NC 27659-'1636
12.Well construction method: MUD'ROTARY
24c.For Water Supply,and Open-Loop Geothermal Raurn Wells:Copy to the
(Le.auger,rolary�cable,directpush,etc'.) county environtnental health degartineift of the county.where installed-
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing.,',er 100,00 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 Method of test: PU M P Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type:73% HTH Amount: 1.5 OZ