GW1--06603_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I ,
James L. Maupin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3517-A 67 ft• 77 ft. Gray Sand
- ft. ft -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Maupin Well Drilling LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 1 ft 67 ft• 11/4 in• sch-40 pvc
398236 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 MATERIAL
gricultural OMunicipal/Public 67 ft. 77 ft. 1 1/4 ern• .010 sch-40 PVC
Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft ft. ;in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1 ft 66 ft• holeplug Gravity
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test -DStormwater Drainage- 67 ft 77 ft OSHA gravity
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ' 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM - TO DESCRIPTION(color,hardness,SulUrocktype Ala 5�,etc.)
1 • ft 5 ft• Gray Brown Clay
4.Date Well(s)Completed:5 Nov 24 Well ID# 5 ' ft 18 ft' yellow sand
5a.Well Location: 18; ft 22 ft tree
Paradise Homes inc 22•- ft 37 ft- Gray sand Clay mixed
Facility/Owner Name Facility ID#(if applicable) 37 ft. - 47 ft Gray clay
140 Lou Sawyer 47 ft• 64 ft Gray'clay and silt.mixe,d_,
Physical Address,City,and Zip 64- ft 77- ft Gray',Sand li ,- ,._..4,.'i__ „i t2,1.
Currituck 040000024B0000 21.REMARKS NIA/ 1 2 2024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees I r,:_:rY.: ? r: _;,�„..
(if well field,one lat/long is sufficient) 22. rtificatio D:c`•,. <::::.:3
J
36.4777462 N -76.068432vf N_N\
9 Nov 24
6.Ls(are)the well(s)�IX Permanent or Temporary f Certified Weu Contractor i �•' Date
By signing this form,I hereby cerltb,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or [jNo 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
-You-may use the back of this-page•to•provide additional-well site details or well - -
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 77 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:C7 (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
Mud Rotaryabove, also submit one copy of this!form within 30 days of completion of well
12.Well construction method: 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 Supply&Injection Wells: In addition to sending the form to
H oehrite 4 OZ -the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: yp Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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