GW1-2023-01016_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: ..�
JOHN PAUL SIMPSOfR'=_C�kVED
'44::WATER10NES
'Well Contractor Name FROM TO I DESCRIPTION
29630—A JAN 2 5 2023 90 % 100 n• LIGHTIGREY SAND
ft. ft.
NC Well Contractor Certification Number ' a t e e+,;t)'ftati Ur-It (S.OUTERiCASiNG'rim ols)4
FROM TO R a"'hcaAble R.>i°
ALJ P ENTERPRISE D
3 it. 90 ft. 12 ' In. SDR21 JPVC `
Company Name
384602 .hf6.�INNERCASiNGORTQBiNG -lo eothkrmalclosedo ., - �`-.- ': „�"5s'•
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.VIC,County,Stag Variance,eta) iL ft. in.
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well: ,._._ i. :
FROM TO DIAMETER, SLOT SIZE THICKNESS 3LITFRTAT.
❑Agricultural ❑Municipal/Public 90 ft• 100 fL 2 in• .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) _MResidential_Water Supply(single) _ __ ft. 90 ft. in.
❑industrial/Commercial 13 Residential Water Supply(shared)
I8:'GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TOP MATERIAL E111PLACEAIENT 11IEIHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• 3/8 bentonite GRAVITY
❑Monitoring ❑Recovery ft. rt. HOLEPLLIG
Injection Well:
ft. ft.
❑Aquifer Recharge []Groundwater Remediation
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEIMENT METHOD
❑Aquifer Test ❑StormtvaterDrainage 20 fL 100 ft- #2 SAND IGRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRtLMG''LOG(attacti'addiddhal'shketsHnkcessa
❑Gcotherinal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrockt size,etc.
0 It- 13 ft- FINE BROWN SAND
4.Date Well(s)Completed: 1/20/23 Wen W#384602 13 fr 21 ft• GREY FINE SAND
5a.Well Location- 21 fL 26 fir GREYfSAND/CLAY/SHELL
TONY DEWEESE 26 ft' 37 ft- GREY SAND/CLAY
Facility/OwncrNamc FacilityM#(if applicable) 37 ffi 84 ft. CLAY
108 NIKKIS LN OLD TRAP SHILO NC 84 rt 100 ft• LIGHT GREY SAND
Physical Address,City,and Zip ft. ft.
CURRITUCK 0389710087690
County Panel Identification No.(PIN) NO SEPTIC,OR HOME ON LOT AT TIME OF DRILL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 C tifi tion:
36 14 08 N 76 01 10 W 20/2023
6.is(are)the well(s): dPermanent or ❑Temporary Si Ce a Wel nlractor Date
B}'s i i this farm,l hereby certify that the ivell(s)was(here)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or InNo 15A 1Y C 02C.0100 or 15A.VC4C 02C.0200 Hfell Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and crplain the nature of the of ithis r Ord has been provided to the hell owner.
repair under#21 remarks section or on the back of thitforM
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 Ovee in Remarks Box).I ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 100 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple+vells list all depths if different(example-3@200'aml 2@10(1)
10.Static water level below top of casing: +4 (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
ff water level is above casing.use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Il.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M U D ROTARY
24c.For Water Supp1V and Open-Loop Geothermal Return Wens:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: tad.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)40 Method of test: PUMP
13b.Disinfection type: 73% HTH Amount: 1.5 OZ