GW1--03527_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C. Veltrl �14:WATEW20NEs
Well Contractor Name FROM TO DESCRIPTION
4368 A 4 fL 28 ft- Yellow Sand
it. ft.
,
NC Well Contractor Certification Number '15 OUTER CASING'for mniti-cased'wells'OR LINER'if" cable "``
Maupin Well Drilling LLC FROM I TO DIAMETER THICKNSESS MATERIAL ` ��"
Company Name 1 fL 21 ft- 1 1/4 in- pr200 pvc
94010 16:=INNER CASING OR TUBING eathermal closed-loo
3
2.Well Construction Permit#: 94 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) fL fL UL
3.Well Use(check well use): ft, ft. 'n'
[Nn
r Supply Well: :17:'SCREEN,;�X .
FROM TO DIAMETERy SLOT SIZE THICKNESS MATERIAL
culturalE)Municipal/Public 21 fL• 28 fL1 1/4 1° .010 S h-4O pvc
thermal(Heating/Cooling Supply) Residential Water Supply(single) & ft. isustrial/Commercial Residential Water Supply(shared) `I&',GROUT ion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Water Supply Well: 1 ft, 21- fLholeplug Gravity
nitoring IIRecovery & fL
tion Well: ft. �ifer Recharge IDGroundwaterRemediation
D/GRAVEL'PACIC ifa` livableifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHODifer Test IDStormwaterDrainage ✓ 21 ft- 28 ft- DSI 1A gravity
erimental TechnologySubsidence Control ft. ft.
thermal(Closed Loop) �TIacer 20 DRILLING;'LOG afresh additional stieets'ifnecessa"` „< rFROMTO DESCRH'TION(color,hardness,soWmck e, ' s�de)
71.
thermal(Heating/Cooling Return) _Other(explain under#21 Remarks) 1 4 Brown Gray Clay
4.Date Welt(s)Completed:$ May 23 Well ID# 4 ft- 28 ft- Yellow S
5a.Well Location: ft. ft.
Judith Contourts ft. ft. MAY 1 a ZOD
Facility/Owner Name Facility ID#(if applicable) ft. fL i
120 South ST. Moyock, 27958
ft. ft.
Physical Address,City,and Zip fL ft.
currituck 008A00000290000 '21 REMARK5'.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
36.54765 N -76,19748
9 May 2023
6.1s(are)the well(s)OPermanent or Temporary Si o C e o ctor . Date
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: E)Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards an4 that a
If this is a repair,fdl out(mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 1 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 if dierent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:4 (W 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 00 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Mud Rotary above, also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary, to the following:tary,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)20 Method of test:pacer pump 24c.For Water Supply&Injection Wells: In addition to sending the form to
H oehrite 2 OZ the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: yp 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 Resource) Revised 2-22-2016