GW1--05169_Well Construction - GW1_20240830

Lill. VII11
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.well Contractor Information:
James L. Maupin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3517-A 47 ft• 57 ft• Gray Sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(if ap licable)
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
1 ft. 47 ft- I 11/4 sch-40 pvc
Company Name 416302 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.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 MATERLA I.
Agricultural DMunicipal/Public 47 ft- 57 ft- 11/4 in- .010 sch-40 pvc
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Ei Residential Water Supply(shared)
la.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft• 46 ft- holeplug Gravity
Monitoring DRecovery ft ft
Injection Well:
Aquifer Recha
rge arge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test JJStormwaterDrainage 47 ft• 57 ft• DSI 1A gravity
Experimental Technology QSubsidence Control ft ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,sod/rock type.grain sat.etc.) )
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) ,- 1 7 ft Brown Gray Clay
4.Date Well(s)Completed:23 Aug 24 Well ID# 7 ft. 9 ft- Gray Clay
Sa.Well Location: 9 R. 17 ft- Gray Sand
Debra Carr 17 ft. 27 ft. Gray Clay --
Facility/Ossnrr Name Facility iD#(if applicable) 27 ft• 37 ft• shell and clay • '•' '
162 Deer Run 37 ft 47 ft• Gray Clay AUG 0 2624
Physical Address,City,and Zip 47 ft- 57 ft• Gray Sand
•
Currituck 0029000000700 21.REMARKS 'r'f'`'Y'" '`'
_.,;
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.Cerd anon'
36.531123 N -76.114853
25 Aug 24
o 'fied Well Contactor Date
6.Is(are)the N xell(s) Permanent or DTemporary
By signing t ' form,I hereby cent&that the well(s)was re)constructed in accordance
7.Is this a repair to an existing well: Dyes or IDNo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under p21 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 57 (ft.) 24a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:5 7/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Mud Rotary above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test pacer pump 24c.For Water SuDDIV& Injection Wells: In addition to sending the form to
Hypochrite 2 OZ the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
i of m G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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