GW1-2021-03453_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: �C
Quible & Associates, P.C. 14.WATERZONES
=Well Contractor Name FROM TO DESCRIPTION
Warren D. Eadus JiUN X 7 2021 3 ft 5 ft md. snd (fill)
5. ft 8 ft fn sand well sorted
NC Well Contractor Certification Number rpcec-sin�g OUTER CASING for multi-cased wells OR LINER if a ticable
3410-B �Ilf.,ir"�t�On FROM TO DIAMETER THICKNESS MATERIAL
D�"6soy S. ction
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: N/A 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 I DIAMETER I SLOT.SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. 3 ft 2 r" 0.10 Isch 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 0 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft. cement pour
ClMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2 ft. 8 fL #2 Sand pour
❑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,sodfrock type,grain size,etc.
0 ft. 5 ft. It brown medium sand fill
4.Date Well(s)Completed: 04/20/21 well ID#AST-MW-1 5 fL 8 ft grey fine sands
5a.Well Location: ft. ft.
Pirates Cove Marina N/A ft. f`
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Tightline Holdings, LLC/ZKT, LLC ft. ft.
Physical Address,City,and Zip ft. ft.
2000 Saiffish Drive Manteo 27954 Dare 21.REMARKS
County Parcel Identification No.(PIN) Bentonite 1-2 feet bgs.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertifrca' n:
35.8942 N -75.6428 W
6.Is(are)the well(s): Permanent or ❑Temporary S ature o ertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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:
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: 8 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
3.1 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is above casing,use"+"
11.Borehole diameter: 4 (in.) 24b.For Injection Wells: Copy;to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Auger 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 over 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