GW1--06281_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri 134AVATERZONES'.$iaZO&t,Wpg: t6q,'AiM-ti:IMMVIAVilMiv.;41,'..ia-'141.?,T',.
FROM TO DESCRIPTION I
Well ContractorName
2 ft, 22 ft. yell:Rome! !
NCWC 4368-A
62 ft* 68 it•
NC Well Contractor Certification Number
`,15:00TER CASING(forinuffi4sised nifis)ORLINER fife' 'h14S411.13•Jrj-ri,T.1,,'I',4
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
-— I it 62 ft 1 1/4 im pr200 ixm
CompanyNarne
:16.INNER CASING OR TUBING(geothermal closed-hirip),- ,:,1,,,;:,.,,,v,,,,,,---,,.., ,•
2.Well 0:instruction Permit#:398276 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable urn consbuction permits(i.e.UIC County,State,Variance etc.) fL ft. in.
3.Well Use(check well use):
W ter
,,.17,SCREEN a Supply Well:
FROM TO DIAMETER SLOT SITE THICKNESS MATER/Al.
li •gricultural 0MunicipaYPublic
62. ft• i 68 ft' 11/4 in' .010 i ndl 40 Px8
A Geothennal(Heating/Cooling Supply) $Residential Water Supply(single) ft. ft. in. 1
I Industrial/Commercial ()Residential Water Supply(shared) 'AS.'OlIOU'Itr:
Irrigation FROM FROM TO MATERIAL EMPLACEMENT METHOD&AMOLINT
Non-Water Supply Well: 1 ft. 60. ft. late phig 91014
Ill Monitoring °Recovery ft. ft.
Injection Well:
ft. , ft.
I •.,;.,,,Recharge °Groundwater Remediation
719 SAND/GRAVEL PACK(if inrilidtbleji,'‘AAAttNAtic-ka)01.N'Nr01..`;,'Ani-K",'!!,07:
I Aquifer Storage and Recovery °Salinity Banier -FROM -- TO -- -MATERIAL ENITTACEMENT METHOD
I •, i ex Tent OStormwaterDrainage 62 ft- 68 ft- dsl 1-A gravel padc Gravity
I Experimental Technology E3Subsidcnce Control ft. . ft.
if Geothermal(Closed Loop) Tracer ,10.DRIELING LOG(attnehirdffithrial skeetiifiveterisary):.;I.',';,,k,,,,,R,',S?CA-A,,1--;i1ON,
Geothermal(fleeting/Cooling Return) nOther(explain under#2I Remarks) FROM ft._ TO ft. DESCRIPTION(colon bantam,solfrock type,gra/.abr.,etc)
4.Date Well(s)Completed:20sept2023
Well DM 2 ft• .; 22 ft- yego,,,sand
52.Well Location: 22 ft- 24 ft• SlaY dPY
-- -- ---' —
•••-•'.-..' 1--...(
Susan Cooper 24 it 38 ft- tidal :--- Z.
shell
Facility/Owner Name Facility lD#(ifapplicable) 36 IL 46 ft- gray day aro shell 1 SEP 2 6 ZOZ3
1729 Tulls Creek Rd 46 f" 62 ft. gray day
' 11141..b i1 i3 7.7.;.:',::::.;;','as..g Ilia
Physical Address,City,and Tap 62 ft. 68 ft.. gray mad 1 t,..A.A:inAtNA
Currituck 003900000110000 -,21.REMARKS'',i?"?',‘.•??,."-zr,c,Wr.:::7;',,.. l.".5",/,';':;`,',-Xt'J'„f,,g4iM1`-`L'It.'l'i;:,',-.'"j*.irK'5„Wil",it,t4-7'e,"„
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) 22.Certification:
36.49401 N -76.06577 w N 'i
ell
6.Is(are)the well(s)OPerm Signature o
anent or °Temporary i
- Date
By signing this lams,I hereby certify that the well(s)Iola(awe)constructed in accordance
7.Is this a repair to an existing well: °Yei or ON° with ISA NCAC 02C.0100 or 15A NCAC/RC.0200 Well COILSfrilah311 Standards and that a
Ythis is a repair.fill out known wellwelicorisiniajon information and ceplain the nature of the copy of this record has been provided to the well owner.
repair under II21 remadzs section or on the badrofthis 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.Yon may also attach additional pages if necessary.
drilled: '•..--
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 68 (ft) 24a.For All Wells: Submit this RUM within 30 days of completion of well
For multiple wells list all depths((different(crumple-3g200..d.2@loo) construction to the following:
10.Static water level below top of casing:8
(ft.) Division of Water Resources,Information Processing Unit,
if water level is above=FIT'.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter:5 7/8 (ut.) 246.For Injection Wells: In addition to sending the form to the address in 24a
hyporchite above,also submit one copy of this form within 30 days of completion of well
12.Well construdion method: construction to the following:
(ie.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)20 Method of test:pacer pump 24c.For Water Snooty&Injection Wells: In laddition to sending the form to
1
the address(es)above,also submit one copy of this form within 30 days of
136.Disinfection type: HYPDeideldte Amount: 30z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromivmtal Quality-Division of Water Resomms Revised 2-22-2016
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