GW1--06479_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHN PAUL SIMPSON 14 WATERZONES '. m.,Fr-. __ . .. i ,
Well Contractor Name FROM TO DESCRIPTION
2930—A 49 ft- 54 ft- LIGHT GREY SAND
ft. ft. I
NC Well Contractor Certification Number
s15:OUTER CASING(fire muln-cased wells)OR-LINER(if aii'heable)
J P ENTERPRISE FROM TO DIAMETER' THICKNESS MATERIAL
+1 ft. 49 • ft. 1.25 i m• SDR 21 PVC
Company Name
P#417680 :16 INNER`CASING OR TI)BING`(gcotherinal dosed-loop) 0?-'7.'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. ; in.
i
Water Supply Well: 17 SCREEN r.. r. . - �7 . .
FROM TO DIAMETER 1 !SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public 49 ft- 54 ft- 1.25 in 4, :010 SDR40 PVC
❑Geothermal(Heating/Cooling Supply) ClResidential Water Supply(single) ft 49 it. in.l
❑Industrial/Commercial ❑Residential Water Supply(shared) ::18..GIfOUT,. <....:. _ . . ,.,
❑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. BENTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -.19:SAND/GRAVEE:PACK(if applicable),, .. . "`'
$ :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft. 54 ft- #2 SAND GRAVITY
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 220.^DRILLING,LOG(attackidditional Sheets it necessary), ,,
❑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)Completed: 9/20/24 Well ID# 2 ft- 11 ft. BROWN SAND
5a.Well Location: 11 ft. 45 ft' GREY SAND FINE
VICTOR G RIVERACAMANCHO 45 ft- 55 It. COURSE LIGHT GREY SAND 1A,2
Facility/Owner Name Facility ID#(if applicable) it ft. "'ti ryrn_1,,:,it— yr 'I. ,'L.,,'
516 KNOTTS ISLAND RD, KNOTTS IS, NC ft, ft. i ''((�� (�
Physical Address,City,and Zip ft. ft. I NO �"24
CURRITUCK 007600000630000 -2t:512EMARKS e. . . rg Ai.., Ai;ti ._-- .._-A un't
County Parcel Identification No.(PIN) f''-r`•. '
T.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Ce tificatio
36.52298 N 75.92596 W
ze
6.Is(are)the well(s): !Permanent or ❑Temporary
Si of ertified Well ontractor I, Date _ r 2-7
By signing this form,i hereby certity that the well(s)was(were)constructed in accordance with
- 7.Is this a repair to an existing well: DYes 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).Yon may also attach additional pages if necessary.
dulled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 54 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi$erent(example-3@200'and 2@100)
i
+7 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)
Information Processing Unit, MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I 1
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) 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
30 PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 73% HTH Amount: 1.0 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018