GW1--01953_Well Construction - GW1_20240325

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Daniel C.Veltri ;;1awATERzoNEs 4v z ,.��. ,r. : '; �.
I '
Well Contractor Name
FROM_ ' TO DESCRIPTION j
20 ft. 27 ft. wa,..s..a
4368-A I
ft. f.t
NC Well Contractor Certification Number 15.OUTER;CASING(for nioltkated/elts).OREINER(if in lieibI4Mit1WitiPt,t,an
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
1 ft• 20 ft. 2 in. sdr-21 �pvc
Company Name
',16 rINNERCASINGOR.TUBING(geotheraiarelosedaUop) .,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable null construction permits(i.e.(BC,County,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): tt ft. is
Water Simply Well: '17.'SCREEN. _hr. . , r, ..,;, . = w .Z : r ,-_<...
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 20 ft. 27 ft. 2 in. .010 ! sdr40 pvc
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in. 1
Industrial/Commercial E3Residential Water Supply(shared)
18.'GROUT_ .. ---. .'
Irrigation FROM TO _MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft 20 ft• holeplug gray ty
Monitoring r3Recovery ft. ft.
Injection Well:
rt. R
quifer Rerbarge °Groundwater Remediation
Aquifer Storage and Recovery °Salinity Barrier ' oM�/GRAVEL PACK'(f applicable) rk-"^ ',
TO MATERIAL EMPLACKWENT METHOD
Aquifer Test °Stormwater Drainage 20 ft. 27 ft. DSI gravel pads Gravity
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20:DRILLING LOG(attack additional sheets'if necessary). ,,t: : ""'
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM To DESCRIPTION(evWr,hanlee�sail/rock type grain sus etc.)
1 ft, 8 f4 yellow brown sand I
4.Date Well(s)Completed:13 Mar 24 Well ID# a ft" ft*�) mPyellow sand
5a.Well Location: H ft l.__. :-., ,,,,,
;, r ; }
James Maupin ft. ft. ^ 1�,;. duG;, 11
' T�ry� —
•
Facility/Owner Name Facility lDff(if applicable) ft. ft.
225 Tatem st Knotts Island 27950 ft. ft 'MAR 6 201.4
Physical Address,City,and Zip f fr Ini, ri,� ern;Err c,.
Currituck (2L'REMARKS.. . ., .. r ot1 R 0 "'_ u 'a .
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.549065 N -76.062036 qr
6.Is(are)the well(s)JPermanent or °Temporary igaatu ell on Date
By signing this form,I hereby certify that the well(s)runs(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or )No 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 captain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details: i
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: 27 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
10.Static water level below topof casing:6
(ft) Division of Water Resources,Information Processing Unit,
if water level is above casing use '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 5 7/8 (in.) 24b.For Injection 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test:pacer Pump 24c.For Water Snooty&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: Hyporchrite Amount: 3 O2 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