GW1-2023-01400_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
- Daniel C. Veltrl 14.WATER ZONES C.
Well Contractor Name FROM TO DESCRIPTION
I
4368-A 16 ft- 32 ft. Sand Shell
�,�-� � s:�;
�� " t ..1�... 68 ft. 74 ft. Gray sand
""NC Well Contractor Certification Number "��"° 7_ ,'
<45.OUTER CASING for.multi-cased'wells`OR LINER'if a useable
Maupin Well Drilling LLC FEB Z1s23 FROM TO DIAMETER THICIINESS MATERIAL
1 ft- 68 ft_
1 1/4I j i°• I pr200 I pvc
Company Name �1ni, t �,16.INNER CASING OR TUBING eothermal,closed-loo "
38471�itury:i�:i�n t r,:. s r�i n:i
2.Well Construction Permit#: FROM To DLu17ETER TSICxNEss MATERrnL y
List all applicable well construction permits ri.e.I11C,County,State,Variance,etc.) ft. ft. ( in
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOTSIZE THICKNESS JMATERIAL
Agricultural �Municipa]/Public 68 ft. 74 ft- 1 1/4 1°' .010 Sch 40 pvc
I Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
IndustrialtCommercial DResidential Water Supply(shared)
18t GROUT
Itil ation FROM TO MATERIALr .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft• 68 ft• Holeplug Gravity
I—Monitoring IDRecovery
Injection Well: ft ft.
Aquifer Recharge nGroundwater Remediation
�,`19.,SAND/GRAVEL PACK if:a livable
Aquifer Storage and Recovery fOSalinity Barrier FROM TO MATERIAL EAtPLACEMMAIEMOD '
Aquifer Test OStormwater Drainage 68 ft. 74 ft. pvc Gravity
Experimental Technology RJSubsidence Control ft. ft.
F Geothermal(Closed Loop) [ITracer 20.,DRILLING LOG attach additional sheets if necessa
F Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM To DESCRIMION color,hardness,soiUroek type,grain she,eta
1 ft- 2 ft- Gray clay
a.Date Well(s)Completed:$ Feb 23 Weu ID# 2 ft. 10 ft. Gray' Sand
5a.Well Location: 10 ft. 16 ft. Shell
.Jeff Meador 16 1-ft- 32 ft. Sand&Shell
Facility/Owner Name Facility]D#(if applicable) 32 fi- 68 ft. Gray Clay
110 Sorrel Lane, Moyock , 27958 68 ft 74 Gray Sand
Physical Address,City,and Zip ft. ft.
Currituck 032A0000013000 21:.REMARKS .r.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.44262 -76.09317
N 2-3
6.h(are)the well(s)JIPermanent or E3Temporary Si citified�WeUC..tracto, � Date
By signing this form,I hereby certify:that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or [@No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 shell Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 74, (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) Construction to the following:
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4 7/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Mudrotary above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test:Pacer pump 24c.For Water Sunoly&InieI lion Wells: In addition to sending the fort to
Hypochrite 4 OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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