GW1--00120_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contactor Information:
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Daniel C.Veltli _-i14.WATER ZONES, .,,f p i- r. '.S.1),IiV 4.,i, R - -4 k r,a ,..1.-
Well Contractor Name FROM TO DESCRIPTION I i
20 ft. 47 n Gray=oacmroaaa
4368-A I
ft. ft
NC Well Contractor Certification Number - -
,15:i OUTER CASING(formollicasWwells)ORLINER(ifappl e)",,,i':•iat
Maupin Well Drilling FROM TO DIAMETER THICKNESS ) MATERIAL
2" n 1 It37 in: sdr21 pvc
Company Name
396307.---- -- — ——-- 16.INNER CASING GRIMING(geoth¢rmatclosed=tuop) -.- ''''`,`,5'",._.;
1 Web Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft. n In.
3.Well Use(check well use): ft. ft. In
Water Supply Well:
FROM TO DIAMETER SLOT SITE .,-THICKNESS MATERIAL
QAgricultuml tMMunicipal/Public 37 n 47 ft* 2' in' .010 ech 40 pvc
°Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) n ft. in.
°Industrial/Commercial E3Residential Water Supply(shared) 18.,GROUT x _ , 's'- '!."
I11rripation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 1 fL 37 n hoteplug Gravitu
Monitoring r3Recovery ft ft i
Injection Well:
ft it.
a • , A Recharge °Groundwater Remediation
''19:'SAND/GRAVEL PACK(if appbnble)) . . i.
MI.•golfer Storage and Recovery °Salinity Barrier FROM TO MATERIAL +EMPLACEMENTMEIHOD
U Aquifer Test 0StormwaterDrainage 37 ft. 47 ft- DSI IA Gravity
II Experimental Technology °Subsidence Control R. ft.
I Geothermal(Closed Loop) °Tracer -20.DRILLING:LOG(attaehadril litnsl heehiifnecessaty)k .?t' Nr..,1P r, ,r,:
FROM TO DESCRIPTION(color,bantam,soil/racktype,grain sin,etc.)
Geothermal(Heating/Cooling Realm) nOther(explain under#21 Remarks)
1 ft. 3 n Crown day
4.Date Wells)completed:24 Oct 23 Well ID# 3 fL 25 fL yelowsand 1 P ^--- -
5a.Well Location: a O' 30 n tidal shell I t ti%.-..
q. r'1� r`
Dave Stroman 30 ft: 36 ft: shell and day mixed f�t-(' .a r Y' L-, ,,,.
- -- Facr7ity/OwmaName-- `-------- Facility lD#(ifapplicablc) "� -30—IL- ii--ff:`-Course Gray sand and shell mixed "r 1. � (1 023
105 Autumn Leaft Ct,Grandy 27939 ft- ft. !nf r7,.,,,:.... ,
Physical Address,City,and Zip ft. ft. D N;i.' ,-;. `7 CIO
Currihlck 108A0000260000 2t:REMARKS as s ..;4. , -..� ;. . ,,L,,
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: • "
36.22923 N -75.87675 W
25 Oct 23
6.Is(are)the well(s)> )Permanent or Temporary Signature ofCettified Well Con
By signing this farm,I hereby awry that the wells)wus(were)constructed is accordance
7.Is this a repair to an existing well: ®Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifrhis is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. .P
23.Site diagram or additional well detal'ls:
8.For Geoprohe/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: 47e (ft) 24a.For All Wells: Submit this form within 301 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@,200'and 2®100') construction to the following:
10.Static water level below top of casing:T (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter:5 7/8 (in.) 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:
(ire.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
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13a.Yield(gpm)30 Method of test pacer pump 24e.For Water Supply&Infection Wells: lei addition to sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b.Disinfection type: Hypochorite Amount: 4oz completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resomor s Revised 2 22 2016

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