GW1--04031_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14.WATER ZONES _
FROM TO DESCRIPTION
Well Contractor Name
2930-A 20 ft- 28 ft- COURSE BROWN SAND
ft. it.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 21 ft- 4 SDR40 PVC
ARH S P# 391399 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',County,State, I uriance.etc) ft. ft. in.
3.Well Use(check well use): ft. fc. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 21 ft- 28 ft- 4 i°• .010 SDR40 PVC
OGeothennal(Heating/Cooling Supply) (,Residential Water Supply(single) ft. 21 g• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- 3/8 holeplug GRAVITY
❑Monitoring ❑Recovery ft. ft. BENTONITE
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft- 28 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(cnbr,hardness,sell/rock type,grate du etc.)
0 ft' 13 ft- DARK BROWN SAND
4.Date Well(s)Completed: 5/10/2024 Well ID# 13 ft- 28 ft- COURSE BROWN SAND
5a.Well Location: it. ft. 1 -• t.�. 1 _•'"r
JOSEPH ANLAUF ft. `Facility/Owner Name Facility lD#(if applicable) ft ft .i U L 0 8 2024
242-A SNOWS LN POWELLS POINT NC 27966 ft. ft.
ArTilili
Physical Address,City,and Zip ft. ft. Irk ,rl v.,,-1r.-•-iwilw
DqiiCit icy:
21.REMARKS
CURRITUCK 012300000370000
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.Certificati
36.14552 N 75.82687 W
5/10/2024
6.Is(are)the well(s): ClPermanent or OTemporary SiWi 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: ❑Yes or l No I SA 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:28 (B') 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@i00')
+5 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 Infection Wells:Copy to DWR,Underground Injection Control(RUC)
I I.Borehole diameter: 8 (in.)
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
13a.Yield(gpm) 15 Method of test: PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.0 OZ
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018