GW1--04032_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
46 ft. 56 ft LIGHT GREY SAND/SHELL SPECS
2930-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
J P ENTERPRISE FROM TO DIAMETER THICKNESS MA IE:ROAt.
+1 ft. 46 ft• 1.25 i"• SDR21 PVC
Company Name
AR H S P# 395426 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM ' TO DIAMETER_ THICKNESSMATERIAL
List all applicable well construction permits(i.e.U/C,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 SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 46 f` 56 ft 1.25 in. .010 SDR40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R• 46 ft' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 ft. 56 ft #2 SAND GRAVITY
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
A 0 ft' 13 ft DARK BROWN SAND
4.Date Well(s)Completed: 6/4/2024 Well ID# 13 ft. 32 ft FINE GREY SAND
Sa.Well Location: 32 ft. 44 ft. GREY SAND CLAY SPECS
JOSHUA&TATIANA BUSHEE 44 rt. 56 It. LIGHT GREY COURS(rSAND SHELL ScE
iFE.
I
Facility/Owner Name Facility ID#(if applicable) ft. ft. I. ``a 11..3
1017 SUMMER WOODS RD GRANDY NC 27939 ft. ft. .!1_11_ 0 8 2024
ft. ft.
Physical Address,City,and Zip
CURRITUCK 010800062JG0000 21.REMARKS ir^;rr•:.i:r•., ,/--rah.c-.?
County Parcel Identification No.(PIN) DI.Ca SC.-tY
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. is Iiiation` ^ 6/4/2024
36.22541 N 75.88051 w /�/
6.Is(are)the well(s): OPermanent or ❑Temporary Signs o • rtified Well Contractor Date
By si. ,_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 InNo /5A 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 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: 56 (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@ 10(y)
+6 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R-) 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 (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.eft 1 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)20 Method of test: PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018