GW1-2023-02190_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri :.14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
---NCWC-.43687A___---- 2 11- 12 ft-
NC Well Contractor Certification Number _14— 24-
lh�sedg`eM'�FO%Mpp li.1d,)
AS;-OUTER L VX,��ASINGJW,multi m""'F
Maupin Well Drilling FROM T ATERIAL
+1 ft- 1 21 ft- 11/4 in- I p,200 pvc
Company Name
'.I&-I.N7NER:CASJ1NG 011: BING(keothertuil
2.Well Construction Permit#:390487 FROM - I TO DLAAMM THICKNESS MATERIAL
List all applicable it-ell construction permits fl.e.UIC Count),,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): n R. hL
" �­.'�'
Water Supply Well: MSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS 1 MATERIAL
DAgricultural DMuniCipal/Public 21 it. 24 ft- 1114 in. oio sch-40 live
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(stripe) fL ft. In.
I)IndustriallCommercial [3Residential Water Supply(shared)
_11rrigation FROM TO MATERIAL EATPLACENILN"r 3=01)&ARrOMT
Non-Water Supply Well: 1 fL 20 ft. holeplug gracity
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge, OGroundwater Remediation
19.'SAND/GRAXTLPAC ifu6plicable)",'
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
DAquifer Test 13Stortnwater Drainage 24 it. 21 ft. DSI 1A Gracity
�)Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer DRILLING LOG(attach additional sheets if necessary)
Geothernial(Heating/Cooling Return) 0Other(explain under#21 RinH!E) rRON1 TO — DESCRIPTION(color,hardness,miltrocii"
1 ft. 2 I'L Clay
-----4.-Datc Well(s)Completed,17 Feb 23 WclI-IDff- —2 _12­-Ir---—ye0cWsand­----
5a.Well Location: 12 ft. 14 ft, gray day
Robert Gregory 14 fi 24 yellow sand
Facility/Owner Name Facility ID#(ifapplicable ft.)
116 Ferry Dock Rd Knotts Island 27950 ft. ft. LJ
Physical Address.City,and Zip ft. f, MAK
Currituck 007800000240000 21.REMARKS
4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one larAong is sufficient) 22.Certification:
36.48497 -76.92312 ........... .............................I'll��:
N
6.Is are the well(s)OPerimment or OTemporary igmft�c i red Well ConRi"M---------Date
,qv signing this form,I hereby cenlry that the im.11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or []No with 15ANCACO2C.0100orl5A]VCACO2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copj,of this record has been provided to the well owner.
repair under#21 remarks section or on lite back ofthis form. 23.Site diagram or additional well details:
8.For Gcoprobc/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-I 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: 24 —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@106r) construction to the following:
10.Static water level below top of casing:7 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:4 7/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Mud Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: pacer pump 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hypochrite Amount: 3 Oz completion of well construction to the county health department of the county
where constructed.
FormGW-I North Carolina Department ofEnvirontnental Quality-Division of Water Resources Revised 2-22-2016

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