GW1--02813_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
JOHN PAUL SIMPSON I
Well Contractor Name FROM TO DESCRIPTION {F
2930—A 20 ft 23 ft BROWN SAND
ft R. I I
NC Well Contractor Certification Number .15:OUTER CASING(for tnoltt-cased tvells)'OR-LINER(if ap"hcable)F
J P ENTERPRISE FROM TO DIAMETER. THICKNESS MATERIAL
ft 20 ft 1.25 in• SDR21 iPVC
Company Name "-16.INNER CASING OR TUBING'(gcothermal closed loop)- _I a° ` '
2.Well Construction Permit#:41 0945 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I. in.
3.Well Use.(check well use): ft ft ti is
Water Supply Well: 17.SCREEN Y;a_ "
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 ft- 23 ft. 1.25 hi-I' .010 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) 1 lResidential Water Supply(single) R• 20 ft. in.
__ DIndustrial/Commercial ❑Residential Water-Supply(shared)
18:GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft 3/8 HOLE PLUG
❑Monitoring ❑Recovery ft. ft BENTONITE GRAVITY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I'
'19:SAND/GRAVELPACK-(if applicable)
❑Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft 23 ft. #2 SAND DSI
❑Experimental Technology ❑Subsidence Control ft. ft I
❑Geothermal(Closed Loop) ❑Tracer 120.DRILLING'IOG'attachadditional'sheets ifoecessa "'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sall/rock type,grain size,etc.)
4 15 24 4102945 0
ft 2 ft TOP SOIL
4.Date Well(s)Completed: Well ID# 2 ft- 23 ft BROWN SAND
ft.
5a.Well Location: ft. - s_,' -
5
DAVID RODGERS ft. ft `-- ' v` �'�
Facility/Owner Name Facility ID#(if applicable)
ft. ft. MAY 0 6 2024
105 SOUNDSIDE EST DR GRANDY ft ft.
ft. ft. Ili°:,:,,--."-;-. P 7:::--• o f .i:-...
Physical Address,City,and Zipj aD Qi'1O;i
CURRITUCK I08B00000020000 '21iREMARKS -'': , -- ,
County Parcel Identification No.(PIN) REPLACE WELL TO FIND BETTER WATER
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22 C frcatio
36 23266 N 75.87218. W i'.
4/15/2024
6.Is(are)the walls): ❑Permanent -or - ❑Temporary -- Si tote of Certifie ell Contractor - Date -
By igning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ❑No 15 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#1I 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 construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface:23 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: +6 (ft) 24a. For All Wells: Original form to'Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test: PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1•0 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018