GW1--02815_Well Construction - GW1_20240506

I
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
John Paul Simpson 14::wATERZONEs :
Well Contractor Name FROM TO DESCRIPTION
2930-A 20 ft. 25 ft light brown sand
ft. ft.
NC Well Contractor Certification Number !15 OUTER.CASING(for inulti-ca`sed'wells)OB'LINER(if-ap`lieable) "x`''-
JP Enterprise FROM TO DIAMETER THICKNESS MATERIAL
+1 ft 20 ft 1.25 f in, sch21 PVC
Company Name 16 3NNERCASING OR TUBING'(geotbermal'clostd=loop) :•7"
2.Well Construction Permit#:#404390 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. tn.
3.Well Use(check well use): it ft I: to
Water Supply Well: 17.SCREEN ' t. _ ' ^` •,:.; .,,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 20 ft 25 ft 1.25 in' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ("Residential Water Supply(single)
ft 20 ft ia.
❑Industrial/Conunercial ❑Residential Water Supply(shared) ,.
I8.GROUT , �- ,� . -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft 3/8 holeplug gravity
OMonitoring ❑Recovery ft. ft Bentonite
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation •19.SAND/GRAVEL-PACK`(ifapplicable) c.' .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft• 25 ft, #2 sand gravity
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) CiTracer ;20:DRILLING?LOG(attacti additional sheets if neces'saryy)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' -10 ft' dark brown sand _
4.Date Well(s)Completed: 3/21/24 Well ID# 10 ft' 25 It light brown Rd--:,-•, --,. ,,7'''',
5a.Well Location: ft. ft I.:—�..r C. 1,9 ^•,i }
Erin Sousa ft. ft MAY 0 (6 111?4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
413 Jarvisburg Rd Jarvisburg NC 27947 ft ft. ' lrti,:,""=rir`.`' .`_'r,a,-;,9 J?i
Physical Address,City,and Zip ft. ft,
Currituck 0109000040k0000 21REMARKS,a= _ , .._, ,.. , .
County Parcel Identification No.(PIN) septic not installed at time of drill service
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 .Certific
36.18884 N 75'85033 w t 3/21/2024
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6.Is(are)the well(s): OPermanent or OTemporary tore of cent ed Well n tor Date
y 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: ❑Yes or QNo 5 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 o its record has been provided to the well owner.
repair under#21 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 pageto provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:25 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
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"+If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy tolDWR,Underground Injection Control(IUC)
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 ova 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)20 Method of test PUMP m P 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