GW1-2021-03238_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael Young 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION I
2 ft. ft.
370-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for.multl-cased;wells OR LINER if a lii able
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 2.5 ft- 0.3 ft- 2 in. sch.40 JPVC
16:INNER CASING OR TUBING(geothermal iaosed-loop),
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.VIC,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
❑Agricultural ❑Municipal/Public 10 ft- 2.5 fL 2 In.lI .010 I SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 10 ft. in,�
❑Industrial/Commercial ❑Residential Water Supply(shared) 7TS.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL IEMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 2 ft. 1 ft- Bentonite Poured from surface
[!]Monitoring ❑Recovery 1 ft. 0.5 ft- Cement Poured from surface
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK;if.•a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 10 ft. 2 ft. #2 Filter sand JTremied through auger
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock gpe,grain size etc.)
0 ft. 1 ft- Gravel,and sand
4.Date Well(s)Completed: 05-26-2021 Well ID# M W-6 1 It. 10 ft- Tan sand j
ft.
5a.Well Location:
ft
Academi Training Facility ft. ft. IV tLj
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
850 Puddin Ridge Rd., Moyock, NC 27958 ft ft. f $ 2
Physical Address,City,and Zip ft. ft. Unit
21.REMARKS n` DwR � .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one lat/long is sufficient) 22.Certification:
36.461907 N -76.202758 W
6/17/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signatu of Certified Weft Contractor Date
By signing this form,I hereby certify th the e11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or I SA NCAC 2 200 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:
S.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: 1 (ft) I
For multiple wells list all depths if di�'erent(example-3@200'and 2@1003 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original fo I to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells:Copy t I DWR,Underground Injection Control(lUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: H O I I OW Stem Auger 24c.For Water Supply and Open Loop Ge thermal 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 Qver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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