_Well Construction - GW1_20230327 (20)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �
Jeovany Gutierrez-Bautista 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4504-A ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased.wells OR'LINER if a Gcable
A.C. Schultes of Carolina, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 65 ft- 24 Carbon Steel
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft- 136 ft. 14 in 316 SS
3.Well Use(check well use): 246 ft. 251 ft- 12 In' I 316 SS
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural IlMunicipal/Public 136 ft' 246 ft 12 in. 50 23" 316L SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
El Irrigation ❑Wells>100,000 GPD FROM TO 11IATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 115 ft. 110 ft. Bentonite Slurry 5 feet
❑Monitoring - d ecavery 110 ft. 0 ft- Cement Slurry 15 yards
Injection Well: va. 7 ft. ft.
❑Aquifer Recharge U q ' 261aroundwatec Remediation
nnAA f� 6, 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and RecFlb ❑Salm;'tyParrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
cj 1ft:
❑Aquifer Test ,. t?t =''. 1'StZrmwater Drainage 115 ft 256 ft. Southern Gravel#3
Oi-
❑Experimental Tech)gy 'VX' - D Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 ft- 10 ft- Soft Sandy Clay
4.Date Well(s)Completed: 3/1/2023 Well m# R04 10 ft• 20 ft- Med.Sand
5a.Well Location: 20 ft' 40 ft- Mixed/Course Sand and Shell
Currituck County 40 ft 60 ft- Brown Clay,Fine Sand,Trace of Shell
Facility/Owner Name Facility ID#(if applicable) 60 ft. 136 ft, Mostly Clay w/traces of fine/course Sand/Shell
153 Courthouse Road, Currituck, NC 136 ft- 200 ft. Mostly Shell,Fine Sand,Small Trace of Clay
Physical Address,City,and Zip 250 It- 280 ft. Mostly Shell,Trace of Clay
Currituck 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36.395256 N -76.021892 W \ 3
6.Is(are)the well(s): InPermanent or ❑Temporary Signiitur erd Well tractor Date o�
is m,I hereby certify that the tivell(s)was(were)constructed in accordance with
7.Is this a,repair to an existing well: ❑Yes or ONo 15A NCAC C.0/00 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out knolvn 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 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:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 256 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple hells list all depths ifdierent(example-3@200'and 2@I00�
55 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljivater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 30 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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) 1250 Method of test: 24 H r.
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 5
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018