GW1--08047_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only 1 . :- (
1.Well Contractor Information:
Daniel C.Veltri
:14.WATEI€ZONESYr',k,,,v. Ko a,..:`' 9" ., m'gi,s. .._ m.,x,x 3:_.
Well ContmctotName FROM TO DESCRIPTION I
4368-A 8 ft S3 it .t....®,r
ft ft
NC Well Contractor Certification Number AS:OUTER CASING(foimidtMaierliiells)ORLaVF[t(itapp1reable .} 4f.i .,j
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS 1 MATERIAL
1 n 34 ft. 11/4 !O' sd21 i pvc
Company Name ,16ANNER CASING°ORTUBING
2.Well Construction Permit ft:4011464 (i eothermai IHCKNEop)
FROM TO DIAMETERTH[CKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): R ft. to.
Water Supply Well: -17.SCREEN .N Z. ..,.; _ 4 .," - ..,
FROM TO DIAMETER SOT SIZE" THICKNESS MATERIAL
11 •y-cultural f MunicipallPublic ft ft is
23 33 11/4 .010 sdr-00 pvc
I Geothermal(Heating/Cooling Supply) °Residential Water Supply(single)
ft ft. in.
*ilndustrial/Commercial EIResidential Water Supply(shared) F OUT _ _ . . ,_ .
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well
1 ` ft 22 ft Hmepliug— — Gravay — - --
Monitoring °Recovery ft. ft.
Injection Well:
ft. R.
i ., . ,R,have °GroundwaterRemediation
19:SAND/GRAV.EL'PACK(ifapplicable)'r. _ -W.,rt ._ ..g';.3-,x
li•• uifer Storage and Recovery ()Salinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
Ill.!•huiferTest 0 Stormwater Drainage 22 ft 33 ft DSI IA Gravely
gi Experimental Technology °Subsidence Control ft ft
IGeotbennal(Closed Loop) ()Tracer .20:DRILLINGLOG(attie6'add;tionalSbeetsffnmcasry) ,,
al Geothermal(Heating/Cooling Return) }Other(explain Ender#21 Remarks) FROM TO DESCRIPTION(mfar,hardness solVmdrtyrhq pm sls eta)
1 ft 2 ft brown sand
4.Date Well(s)Completed:2 Oct 23 Well ID# 2 ft' 6 R- light brown day
5a.Well Location: s n 8 R tree
Quang Nguyen 8 ft. 33 ft yellow brown sand Fine T?^ j. ' --'' 't, f I )j
-
Fact7itylOvmerName Facility ID/i(if applicable) ft. ft.
204 Parker Lane,Knott's Island 27950 fc ft Di-r, i i [Q L 3
Physical Address, Zip ft ft.
hys City,and l .n• I.h
Cutrituck 0077000085Y0000 21';REnrnRKS ;. 3 ' ,.. ,, ., , uur,lft ,uh wr_-Z,4- _.
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) ——
22:Cfstr tion:-- ? — -
36.501 s4 N -75.91080 W (/L/ 3 ilia 23
6.Is(are)the wells)(aPermanent or ()Temporary Signs ell Contractor . 1 ti Date
By signing this font;I hereby certify that the well(s)Inas Anew)am structed in accordance
7.Is this a repair to an existing well: ®Yes or EiNo with ISA NCAC 02C.0'00 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the copy aphis record has been provided to the well owner.
repair under#II 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.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33 (ft-) 24a.For All Wells: Submit this foam within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3Qa 200'and 1Q100) construction to the following:
10.Static water level below top6
of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing use"i-" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter:5 7/8 On-) 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
12.Well construction method. construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test:pacer pump 24c.For Water Supply&Injection 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: Hyporchroite Amount: 2 oZ completion of well construction to the county health department of the county
r
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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