GW1-2021-00472_Well Construction - GW1_20210210

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
Well Comma.,Name FROM TO DESCRIPTION
2370-A
n. «.
NC Well Contractor Certification Mother 15.OUTERCw L he
ING RNRg
Fishburne Drilling Inc. DIMETEw
MATERIAL
«. R io.
Company Name
16.INNER CASING OR 1'DBR4G el
2.Well Construction Permit 4: Mom TO DIAMETER THICKNESS MATERIAL
Liar all applirable well eoru'huerion permits/i.e UIC.County.Score. Faruoue,e10
3.Well Use(check well use): n. fL in.
jAnquifer
ter Supply Web: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultural �MunicipaVPublic 10 «• 2s «- 2 la otn sch,a0 pvc
eothermal(Beating/Cooling Supply) Residential Water Supply(single) p ft ID
ndustrial/Commercial Residential Water Supply(shared) is.GROUT
Irrigation FROMIn
TO MATERIAL It PLACEMGT METHOD&AMOUNT
n-Water Supply Well: 1.5 1.0 n- bentemem pound from surface
Mmiwring Recovery 10 0.9 n- Cement poured from surface
ection Well:
a
quifer Recharge QGroundwa[er Remediation
19.SAND/GRAVEL lACR
Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test "Stormwater Drainage 10 n• Is It- 41 fact sand treatment through auger
xperimental Technology Subsidence Control «. fL
eothermal(Closed Loop) Tracer 29.DRD.LDVG LOG a«aeh admlMel rhnb R
FROM TO DESCRIPTION alas harasew,miVrxk de
rwthemlal eatin Conlin Rehm) Other(explain under N21 Remarks)
0 «• 05 It. gavel
4.Date Well(s)Completed:01-11-2021 Well ID#MW-4 05 n. a f. gre,,_hmawntlay wl oroames
5s.Well Location: n' 10 It. stay fine sera
ACADEMI Training Facility `L °-
Facility/Owner Name Facility ID4(ifapplieuble) n. n-
850 Puddin Ridge Rd., Moyock, NC. n. It.
Physical Address,City,and Zip n. It.
Currituck 21•REN ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 22.Certift
36.461594 N -76.202605 W ce
01-13-2021
6.Islam)the well(s)opermanent or Temporary Signature of Ceamed Well Qiintraw Date
B_1'.signing this form,I hereby cerr:that th life) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or MNo wish 15A.NCAC 02C 11/!XI or ISA h'CAC 0 .0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature ofthe copy`this record has been provided to the well owner
repair under 421 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of WAIIT, ' e '.,construction details. You may also attach additional pages if necessary.
drilled: ` . ...
-- .. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10 .`24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdffereat(example-3*200'arWlwlpf('JCO coustruFlion to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
!f»rater level a above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,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,mazy,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& Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this Form wthin 30 days of
13b.Disinfection type: 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