GW1--06487_Well Construction - GW1_20241104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
JOHN PAUL SIMPSON la.WATER.ZONEs
Well Contractor Name _FROM TO DESCRIPTION
2930-A 56 ft- 61 ft- LIGHTIGREY SAND
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedrwells)`OR LINER(if an licable) "s ;*•'°
J P ENTERPRISE FROM TO DIAMETER THICKNESS MATERIAL,
+1 ft. 56 ft- 1.25 in" SDR21 PVC
Company Name �/
ARH S P li`t 1 6407 IC INNER CASING OR:TUBING.(gcothermal closed-loop) V `�'
..v
2.Well Construction Permit#: 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 in.
Water Supply Well: 17t.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 56 f- 61 ft- 1.25 in" .010 SDR40 PVC
❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft. 56 8. m,i
❑lndustrial/Commercial ❑Residential Water Supply(shared) •:18
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 It. 318 HOLEPLUG GRAVITY
OMonitoring ❑Recovery ft. ft- BENTONITE
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
:19.SAND/GRAVEL;PACK(if applicable), ,
❑Aquifer Storage and Recovery ❑Salinity Bather FROM , TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 20 ft- 61 ft- #2 SAND GRAVITY
❑Experimental Technology 0 Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer .'20.DRILLING I OG(attach additional sheets if,necessary) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grab size eta)
0 ft' 2 ft- TOPSOIL
4.Date Well(s)Completed: 10/9/24 Well ID# 2 ft- 13 ft- BROWN SAND CLAY MIX
5a.Well Location: 13 ft• 23 ft• FINE GREY SAND CLAY
GREGORY REINHARDT 23 ft. 51 ft• FINE GREY SAND,SHELL,CLAY
Facility/Owner Name Facility ID#(if applicable) 51 ft• 61 ft- COURSE LIGHT GREY SAND/SHELL ,
665 GRIFFIN SWAMP RD ELIZABETH CITY, NC 27909 ft. ft.
Physical Address,City,and Zip ft. ft.
PASQUOTANK 8839262018 4`?"
��21`:REiilARxs __� . __ ,4 �_:,-
County Parcel Identification No.(PIN) WELL 100 FT PLUS FROM SEPTIC SYSTEM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. _„ 6„ ` ' ,'t'•'.':Li Certification: V �;�; ,� +o ,�, �,�,� �'
36.17690 N 76'18099 W y
Q,�- ;,6,. ' • Npvt) 42024 'a •R' .2y
6.Is(are)the well(s): dPermanent or ❑Temporary Sigture of Certified We Contractor Date
By signingi this form,I hereby certii,t/>EjGhais'el1C)lms(iveke:TalisPatcigpl accor dance with
7.Is this a repair to an existing well: ❑Yes or dNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 E111:Coiistre-tcLion Standards and that a copy
If this is a repair,fell out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back ofthis 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: 61
(ft) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if dferent(example-3@200'and 2Q100)
-I- 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6 (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 to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M U D 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 I over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)30 Method of test: PUMP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 73% HTH Amount: 1.5 OZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018