GW1-2021-00473_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
FROM TO DPSCRIPTION
Well Contractor Name � R.
2370-A
ft. R
NC Well Contractor Certification Number I&OUTER CASING for matif-amed wen OR LINER if o 'cable
Fishburne Drilling Inc. FRoM TO DIAMETER THICKNESS MATERIAL
k. n. t•.
Company Name 16.INNER CASING OR TUBING rmal do"4
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consrruction permits(71 a UIC,County,Sour.Vertance,etc.) R. ft. In.
3.Well Use(check well use): ft' ft' nn
/7.SCREEN
jrter Supply WelU Rom TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic 15 ft. 50 it 2 in- atD scb.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaVCommercial QResidential Water Supply(shared) it GROUTf
Irti tion FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
on-Water Supply Well: 3.0 fL 1.0 ft beakefte poured ham surface
Monitoring Recovery 1.0 fL D fL cemam poured from surface
Injection Well: ft. h
Aquifer Recharge QGmundwater Remediation
U.SAND/GRAVEL PACK • able
Aquifer Storage and Recovery �Selinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage 15 ft• 3.0 ft- #2 finer santl immetl through augo
Experimental Technology Subsidence Contml
Geothermal(Closed Loop) Tracer 20.DRML94G LOG attach additional meets if necessary)
Gcothcnnal (Heating/Cooling Return) Other ex lain under#21 Remarks room TO DESCRIPTION(mar,herdam,w rerk m sine,et0
o ft• 0.5 R gmvd
4.Date Well(s)Completed:01-11-2021 Well ID#MW-5 0.5 & 4 It. gray-browadayw/organic.,
So.Well Location: 4 ft- is it. gray fine sand
ACADEMI Training Facility a m
Facility/Owner Name Facility lD#(if applicable) ft. R
850 Puddin Ridge Rd., Moyock, NC. ft' m
Physical Address,City,and Zip ft. fL
Cunituck 21.REMARKS
County Panel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat long is sufficient) 22.Certification:
36.461703 N -76.202808 N
01-13-2021
6.Is(are)the well(s)OPer'manent or Temporary Signature ofCenified Well Contractor Data
By signing this form,I hereby certify that the weil(s)was(were)conrnsencd in accordance
7.Is this a repair to an existing well: OYes or ONO with ISANCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards turd that a
If this is a repair,fill out brown well construction information and explain the ware of the copy oftles retard ban been provided to the dell owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For Geuprobe/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: 10 -•" {ft•) 24. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdillirem(esample-3@200'da 2" 0: q p�1 construction to the following:
10.Static water level below top of casing: r O 1 ® Lm{kk' Division of Water Resources,Information Processing Unit,
If ester level is above casing,use"+" _�C�- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For lulection Wells: In addition to sending the form to the address in 24a
t ' above,also submit one copy of this form within 30 daysp
of completion of well
12.Well construction method: Auger h, , construction to the following:
(Le.sugar,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) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

ACADEMI/Moyock,NC
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LEGEND
Previous Temporary Monitoring Well Associated with Impacts
Proposed "Shallow" Monitoring Well Location
Proposed "Deep" Monitoring Well Location
• Pro
0 FIGURE 2
SOURCE: PROPOSED MONITORING WELL LOCATION MAP
GOOGLE EARTH Ram Pad Area
IMAGE TAKEN MAY 2,2018 ACADEMI Training Facility
SCALE AS SHOWN ABOVE 850 Puddin Ridge Road
Moyock,Camden County, North Carolina
0 ECS Project No. 49:8246-E