GW1--06475_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON I
14:WATER.ZONES _ - - -'f -.
Well Contractor Name FROM TO DESCRIPTION -100 it 110 ft• GREY SAND FINE SHELL SPEC
2930-A
ft. ft.
NC Well Contractor Certification Number 45:OUTERCASING(Mk niulti-cased,iwells)`ORLiNER(ifap'Lcable)i s it,
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL
-- +1 ft• 100 ft• 1.25 1 in. SDR 21 PVC
Company Name
16.INNER CASING OR TUBING(geotherinal'closed-loop) , ' `'
2.Well Construction Permit#: ARHS#419143 FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e UIC,County,Stale,Variance,etc.) ft. ft. " in.
3.Well Use(check well use): ft. ft is
Water Supply Well: 17c4SCREEN t. w _ _ ' Ir:z a �x
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 100 ft• 110 ft- 1.25 in'i .010 SDR40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 100 ft• in.
❑lndustrial/Cornmercial InResidential Water Supply(shared) 18:GROUT '
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT n
Non-Water Supply Well: 0 ft• 20 ft• 3/8 HOLEPLUG GRAVITY -=li , ? tr, "' I
❑Monitoring ❑Recovery ft• ft• BENTONITE /,
Injection Well: ft ft. Null 0 �' 2024
DAquifer Recharge ❑Groundwater Remediation -;:19:SAND/GRAVEL PA'CK+(if"applicable) r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT•METIfOD' •'i
❑Aquifer Test ❑Stormwater Drainage 20 ft 110 ft• #2 SANG GRAVIW
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20 DRILLINGLOG'(attaeh additiorialsheets if necessary) x.. „-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
0 ft• 2 ft- TOP SOIL
4.Date Well(s) Well Completed: OCT 2 2024 We ID# 419143 2 ft• 11 ft. BROWN SAND/CLAY
5a.Well Location: 11 ft• 42 ft• FINE BROWN SAND CLAY
BENBURY WOOD&FLORA DAVIS 42 ft• 92 ft• CLAY,FINE SAND,SHELL SPEC
Facility/Owner Name Facility 1D#(if applicable) 92 ft• 110 ft• GREY SAND/SHELL SPEC
250 GREENFIELD RD ft. ft.
Physical Address,City,and Zip ft ft.
CHOWAN 785400397240 ,21 REMARKS . = ,_ *. :, _ _€ .1, '.
County Parcel Identification No.(PIN) EXISTING WELL GALVZ IRON 36'NO YIELD,OR DATE,GW-30
SUBMITTED
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Ce ')'cation•
36.05656 N 76.44454 W /
I V Z_ z�
6.Is(are)the well(s): InPermanent or ❑Temporary Signa "of Cert ed Well Co for Date
Bys/ing this form,Thereby certify that the xell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Yes or ❑No 15A NCAC 02C.0100 or 1SA 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: 0 (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 2Q100')
+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"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy tol DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: MUD 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
7 PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 73% HTH Amount: 2.0 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018