GW1--01951_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
1
Daniel C.Veltri .,14.MATER ZONES ,' ,
FROM TO DESCRIPTION I I
Well Contractor Name
28 it 38 ft• rem,de.and I
4368-A
ft. ft.
NC Well Contractor Certification Number
EIS-OUTER CASINGViii,mblii4,6q.d.iieils)ORLINER(if al,'lierthlerri .',, ,..,..:-....', -
Maupin Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
1 ft• 28 ft• 1 1/4 In. sch-40 pvc
CompanyName
,--,46.INNER cAsING OKTUBING(geatheimitelosed-loop)--.,":-.^-:"1.,',,.if•..,-.'",,-,.; ..-... -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:403478
List all applicable well construction permits(i.e.(JIC,County,State,Variance,etc.)
in.
3.Well Use(check well use): ft. ft.
A7.SCREEW-, ‘0".,.,-,,,,-,-,.-:,°-,„' ,-
WAater.Supplyult Well:
FROM TO DIAIVIETER SLOT SEM : TMCKNESS MATERIAL
Municipal/Public 28 ft• 38 ft• 1 1/4 ill .010 , Cch-413 pvc
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in, I '
Industrial/Commercial r3Residential Water Supply(shared) ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft. 28 ft• Holeplug Graity
Monitoring EDRecovery ft. ft.
Injection Well:
ft. ft.
quifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if Mittlicable) .•.7.,,,,.7-. ,;Z)qi,-.'/;=',:-% ,..',,;1',..',?•.Y.. ,,r'-.,-...---1r;•,
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test 0 Stormwater Drainage 28 ft• 38 ft. 1A DSI Gravel gravity
Experimental Technology °Subsidence Control ft. IL
Geothermal(Closed Loop) °Tracer .:20.DRILLING LOG(attach additional sheets if necessary Y;:,......
FROM TO DESCRIPTION Odor,hardn as,sail/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) riOther(explain under#21 Remarks)
1 ft• 2 ft. brown gray clay
4.Date Well(s)Completed:15 Mar 24
Well EDI/3 2 ft• 22 ft" yellow sand
'1 1' f t. Ye c" F t iti ": 2;il:-. :'\ 1177
ft ft.
5a.Well Location: . . 24 peatu moss
sand -
Sierra Baker 24 ft. 28 ft• gray clay
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Facility/Owner Name Facility ID#(if applicable) 28 f t.
Lot#6 Newbems Landing. Jarvisburg,27947 ft. ft. - " V L.,Le
Physical Address,City,and Zip ft. ft. 1A1 2074
Currituck 110G00000060000 k2tItEmAnits',;`,.-,A::e.,-,'A....',,,:,-.a., .L,..•:,-=.‘...:'.., •-,:,-,.-,'_',,c' -4. ,i.... .;..„;-_,...;;•..,
........ .:
tilit.,1 ri.1.3zn pp-,- : .
County Parcel Identification No.(PIN) ,, .- -wa.rm,i.Ag,
CA4 i'. ..)t3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.16097 N -75.85959 i
W
i 1 9 mar 24
6.Is(are)the well(s)OPermanent or Temporary ',mature ed Well Contractor ; Date
1
By signing this form,I hereby certfly that the sell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or E)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
'phis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well°Ismer.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 38 (ft.) 24a.For All Wells: Submit this form within 130 days of completion of well
For multiple wells list all depths if different(example-3@,200'and 2®100')
construction to the following:
10.Static water level below top of casing:6
(ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5 7/5 On-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Mudrotary 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 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
orchrite
13b.Disinfection type: hyp Amount: 3 oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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