GW1-2023-02466_Well Construction - GW1_20230404

WELL.
RECORD(GW-1) For Internal Use Only.
4L Well Contractor Information:
Daniel C.Veltri _-I4.WATERZ0N]KS,!,
Well ContractorName FROM TO I DESCRIMON
88 ft. 98 ft.
NCWC 4368-A
NC Well Contractor Certification Number As.,OUTER CASING­0xr
multi cosed.xdh Maupin Well Drilling FROM I TO M==_x.'_rMMATERIAL
Company Name I % 1 88 & 4 in. I pr 2DO r , ipm
.;I&114NM CASING OR, ING(Reotherand closed4ourv),,,
2.Well Construction Permit#.391086 FROM I TO DLA14MM I THICKNESS MATERIAL
List all applicable rill construction permits(ce.IMC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): % ft.
Water Supply Well: 17a SCREEN ,','.
FROM TO DIAMETER SLOT SUE MUCENESS MATERIAL
3Agricialtural [3Municipal/Public 88 It* 98 ft. 4 -010 sch-40 PVC
lGeothermal(Heating/Cooling Supply) [@Residential Water Supply(single) ft
% in
Industrial/Commercial [3Residential Water Supply(shared)
J&GROUT%,
Ifirigation, FROM I TO MATER]AL EMPLACIMUENT ME717HOD&AMOUNT
Non-Water Supply well: 85 f4 surf ft. hole plug gravity
3Monitoring 13Recovery ft. fi.
Injection well: it. fl.
3Aq.ff-Recharge [3Groundwater Rentediation
3Aquifer Storage and Recovery OSalinity Barrier FROM I TO I NUTERUL EMnACEMENT METHOD
Aquifer Test []Storinwater Drainage 88 ft- 98 it DSI 1A gravity
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Txacer DR[LLING'LOG'attach'nddinonal shirts if
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO IDESCRIFIrION(calor,hwdmvk soilfrock tnw.gnia svm�etm)
78 ft- 88 ft• gray clay
4.Date Well(s)Completed.117 Mar 2023 weum# as ft. ga fL shell and snad
Sm.Well Location: tt %
Joeffi,ey Martin
Facility/ownerNarm: Facility IDff(ifappticable) rL n el 7
A.RR
125 Sandy Point rd Knotts Island,27950 A-23
Physical Address,City,and Zip ft �fL in' r Z, lri J
Currituck 0046000001B000 21.REM z;
County Parcel Identification No.(PIN) JReplacement well
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
36.548958 N -76.004680 2o A e r 23
6.Is(are)the well(s)OPermanent or [:)Temporary I r�urcwi!W.11 Co Contrac-ffi?-- Date
By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the well owner.
rqufr under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For GeoprobcIDPT 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.
Mlle' SUBM][TTAL INSTRUCTIONS
9.Total well depth below land surface: 98 —(fL) 24a.For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ifilifferen t(example-3 @200'and 2@100) construction to the following:
10.Static water level below top of casing.22 (ft) Division of Water Resources,Information Processing Unit,
ffivaler level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. 7 7/8 24b.For Infection,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
IL Well construction method
construction to the following.
(Le-auger,Inlay,cable,directpush,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)7 Method of test: 1/2 10 pump 24e.For Water Supply&Iniection Wells In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hyporchrite Amount 6oz completion of well construction to the county health department of the county
where constructed.
F(nmGW-1 North Carolina Department of Environmental Quality-Division ofWater Resources Revised 2-22-2016

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