GW1--04006_Well Construction - GW1_20240708

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 71 ft- 81 ft- LIGHT GREY SAND/SHELL SPECS
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a ble)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL _
+1 ft. 71 ft- 1.25 in- SDR21 IPVC
Company Name
A R H S P# 402609 16.INNER CASING OR TUBING(geothermal dasedaoop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Wen: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 71 ft- 81 ft 1.25 in. .010 SDR40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 71 ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.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.
Injection Well: -
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applcable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft- 81 ft- #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(odor,hardness son/rock type,grain sirs,etc.)
0 ft• 13 ft- DARK BROWN SAND
4.Date Well(s)Completed: 6/11/2024 wen ID# 13 ft- 32 it• FINE GREY SAND
5a.Well Location: 32 f' 68 ft FINE SAND, CLAY, SHELL
KARLIE WILSON 68 it. 81 t LIGHT GREY SAND SHELL
Facility/Owner Name Facility 11#(if applicable) ft. ft. F.;L.:`,L.,1,/F L1
1430 US HWY 17 ELIZABETH CITY NC 27909 ft. ft
Physical Address,City,and Zip ft. ft J U L J 8 2024
PASQUOTANK 21.REMARKS
I140:-.T,.. .. ''''a+':, .L'Jri.
County Parcel Identification No.(PIN) O't*::_„$`-j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/bng is sufficient) 22. ►• illation:
tj
36.25504 N 76.31075 wVtractor
6/11/2024
6.Is(are)the well(s): OPermanent or ❑Temporary Signs o • ifie Date
By si: .:this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or GNo 1SA N C 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#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 page to 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:81 (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 1@100)
-(6 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M U D 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) 30 Method of test: PUMP
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018