GW1--04028_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2930-A 20 ft• 28 ft• COURSE BROWN SAND
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft' 20 ft' 4 in.
SDR40 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• NA 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 Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 rt. 28 ft. 4 in. .010 SDR40 PVC
L Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. 20 ft' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
Obligation ❑Wells>100,000 GPD FROM TO -- MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 f`• 3/8 holeplug GRAVITY
OMonitoring ❑Recovery ft. ft• BENTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 ft 28 ft• #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Hardness solVroek type,min ritt etc.)
0 ft. 28 ft- BROWN SAND COURSE
4.Date Well(s)Completed: 6/19/2024 Well ID# ft. rt.
ft. ft. r = `_r.. ..*1 5a.WellLocation: 1 . . /E ^)
DENNIS HITCHCOCK H. fL
Facility/Owner Name Facility ID#(if applicable) ft ft. J IJ L 0 2024
136 WATER ST HARBINGER NC ft. ft.
--- lrAarR-.4.i.as1 a^r.^aria:-.g Liar
Physical Address,City,and Zip ft�t DsfliC.sc4
CURRITUCK 21.REMARKS
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatl
36.09817 N 75.80278 w 6/19/2024
6.Is are the well(s): L(Permanent or ❑Ten ra Si tore of Ceni Well Conine 1 Date
Is(are) Po ry
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ClYes or ❑No ISA NCAC 02C.0100 or 1 SA 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#11 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 I 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: 28 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a?200'and 2(4100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: +5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 8 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M LID 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 27699-1611
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