GW1--03165_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
Daniel C.Veltri 'IAL WATERZONES
I
Well Contractor Name FROM TO DESCRIPTION-Et -
NCWC 4368-A 2 28
I,
NC Well Contractor Certification Number '15.0 FROM To
116r ia!gtWjgs,OR irap�Wable
Maupin Well Drilling
I It- 1 21 ft' 1 2 in. pr2oo MATERIAL
Company Name pvc
16.INNER CASING OR TUBING(geather closed4odo)-,
2.Well Construction Permit#.363905 FROM I TO I DIAMETER THICKNESS 31ATERLAL
List all applicable uvfi construction permits(Le UIC,County,State,Pariance,etc.) ft. fL In.
3.Well Use(check well use): ft fL
hL
Water Supply Well: 17.SCREEN
W FROM TO DIAMETER SLOT SUE THICENESS MATERIAL
Agricultural []Municipal/Public 21 Ft- I R. 2 hL 010 sch-40 PVC
3Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
3Industrial/Commercial E)Residential Water Supply(shared) IS.GROUT
-1hrigation FROM I TO I MATERIAL EMPLAMUNT METHOD&AMOUNT
Non-Water Supply Well: 1 fL 20 It. Weplug gravity
3Monitoring pRecovery fL R.
Injection Well: ft. It.
3Muifer Recharge [3Groundwater Remediation
19.,SAND/GRAVEL PACK(if applicable)-",;
3Aquifer Storage and Recovery E]Salinity Barrier FROM I To MATERIAL EMPIACF.MINT METHOD
3Aquifer Test []StOnnwater Drainage 21 ft- 28 lf- ds!1A gravtty
Experimental Technology [3Subsidence Control H. ft.
Geothermal(Closed Loop) [jTmeer 20.DRILLING LOG(attach additional sheets itueeksary)."
g
FROM TO I DESCRIF11ON(mlor,hardness,Sufrwk type,gmn sax,dc.)Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 1 0 ft- 2 ft, brown cl.ay
4.Date Well(s)Completed:13 April 23 Well ID# 2 ft 28 ft. yellow sand
Sa.Well Location: ft. ft. .
f �—P.
Thomas Williams t R. ,
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft.
135 Foxx Lane.Knott's Island NC,27950 ft. ft. (Ut-i
Physical Address,City,and Zip %
Currituck 00770000095AOOOO 2l'.REd%1ARKS_
County Parcel Identification No.M
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
36.499953 N -75.91096
6.Is(are)the well(s)oPermanent or [3Temporary to ell Con Date r
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ®No with 15ANCACO2C.0100o'rISANCACO2C.0200 Well Construction Standards and that a
ff this isa repair,fill out known well construction information and explain the nature afthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
8.For Geoprobc/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: 28 —00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(crample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:2 (ft.) Division of Water Resources,Information Processing Unit,
V'water level is above casing,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter. 5 7/8 (in.) 24b.For In I"ection 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 we
12.Well construction method: well construction to the fiallowing-
(.c.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 276994636
13a.Yield(gpm) 15 Method of test:pace,pump 24c.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: hypochrite Amount 4 oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of WaterResources Revised 2-22-2016