GW1--04029_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 50 ft, 60 ft. COURSE GREY SAND/SHELL SPEC
ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 50 rt• 1.25 SDR21 PVC
Company Name
A R H S P# 414 316 16.INNER CASING OR TUBING(geothermal closed400p)
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 Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 50 ft- 60 IL 1.25 in• .010 SDR40 PVC
)Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft. 50 ft• in,
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 1t' 20 ft. 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft• BENTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 ft 60 ft. #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(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 soiUrock type,grain size,etc.)
0 ft. 13 ft- BROWN SAND COURSE
4.Date Well(s)Completed: 6/25/2024 Well 1D# 13 ft• 32 ft. FINE GREY SAND/CLAY
5a.Well Location: 32 ft 46 ft• FINE GREY SAND/SHELL/CLAY
DORIAN OWENS 46 ft. 60 rt• LIGHYT GREY SF`D� Ht7 �
Facility/Owner Name Facility ID#(if applicable) ft. ft.
204 HARBINGER RIDGE RD HARBINGER NC 27941 ft. ft. JIJL 0 8 2024
Physical Address,City,and Zip ft. ft. IFits;14:146ii:3.4'7.-sew 4.-uot
CURRITUCK 0125000027A0000 21.REMARKS p� (-
County Parcel Identification No.(PIN) EXISTING WELL LETTING IN EXCESSINID
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificati
36.09551 N 75.82563 W
�.-Q�� 6/25/2024
6.Is(are)thewell(s): llPcrnianent or I ITemporary Si true ofCerti a Well Contrac r 1 Date
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: ftYes or ❑No 15A 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#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: 60 (ff•) 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')
+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"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:6 On.)
MUD ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)20 Method of test: PUMP
13b.Disinfection type: 73% HTH Amount: 1 .0 OZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018