GW1--00121_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: •
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Daniel C.Veltri :14.WATERzoNEVA ti;F.u..:.,t , i ,4,:." "t.. , .... ';;
FROM TO DESCRIPTION I ,
WellConnactorName R. 1 j .
4368 A 62 fL 68 tt core
NC Well Contractor CenificationNumber 15.OUTER CASING(for mDlli 'd wills)OR LINER Cif'applinble) ;-KF .. ,
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS ll MATERIAL
1 ft- 62 ft- 2 in, sd21 pee
Company Name
361955 - 16.INNER CASING OR TURING'(geothen;mar closed-loon)_i; "'' ..>.',
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2 Well Construction Permit -------FROM- -- TO DIAMETER THICKNESS - MATERIAL
List all applicable nett construction permits(Le.UIC,County,State,Variance,etc) fL ft in.
3.Well Use(check well use):
n ., in.
Water Supply Well: FROM TO DIAMETER SLOT STZE THICKNESS MATERIAL
Y Agricultural E3Municipal/Public 62 ft- fib fL 1 1/4 in' .010 snit 40
al Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) (t, ft. is '
III Industrial/Commercial °Residential Water Supply(shared) •18.'GROUT _> n t ,.F w 4 r.,•_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft- 61 IL hdeptug gravity
ill Monitoring ()Recovery ft. ' ft
Injection Well:
ft. ft.
Y uifer Recharge °GroundwaterRemediation 19:SAND/GRAVEL PACK(if iippbcahle)r"a)i w: ,-:sk ,w
It., ' W Storage and Recovery ()Salinity Barer FROM TO- MATERIAL ' EMPLACEMENT METHOD •.
jil-Aquifer Test 0Stormwater Drainage • 62 ft- 68 ft- pvc : gravity
R Experimental Technology EitSubsidence Control ft. • ft.
Geothermal(Closed Loop) ()Tracer r20.DRI LLINGLOG(atlaehadditiomilsheets"ti'nucssai) ;, .c.. ,'_. a f-.X
ili Geothermal(Heating/Cooling Return) ()Other(explain under#21 Remarks) FROM TO DrSC.111M N(rainy esn soi lrodr Type, sdm'etc)
1 ft. 8 ft. brown sand i
4.Date WeR(s)Completed:17•Oct 23 Well DV a it, 10 fL tool moss I '
5a.Well Location: w ft- 14 ft. grayday ram:
�
Charlie Canupp 14 ft- 28ft- yellow sand , t'�:,.1'. ,�:,_ ?r 1
2 ,.
Facility/Owner Name Facility lD#(if applicable) 28 - - -7-� ft.
107 E point Estates Ct Knouts Island 27950 ' 44 ft. 60 ft' gray clay , DEC 3 8 2023
Physical Address,City,and Zip 60 II. 68 ft- gray sand 1 fl, I .,
Currituck 055A00000070000 .:2BREMARRS. r " '^.:. t i
\ 'iC oC .I ;r.t
County Parcel Identification No.(PIN) J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: \
(if well field,one lat/long is sufficient) 22.Certifica' . I v
36.54380 N -76.00486 W
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6.Is(are)the wel(s)JPermanent or jTensporary oft I Date
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By signing this form,I hereby certify that the xrll(s)uos(wee)constructed in 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
If this is a repair,fill out known well construction information and erp/ain the nature optic copy of this record has been provided to the well owner.
repair carder till remarks section or on the back ofthisform.
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: 68 (ft) 24a.For MI Wells: Submit this form within 30 days of completion of well
For mutilate welts list all depths ifdifferent(example-3Q200'and 2@100') construction to the following:
I.
10.Static water level below top of casing:12 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
IL 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.
e.aug
er,ge,rotary,cable,direct push,etc.)r. ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test:pacer pump 24c.For Water Supply&Injection Wells: la addition to sending the form to '
the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: Hyporchrite Amount: 3 oz completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016

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