GW1-2021-03454_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: P.C.Quible & Associates, C 14.WATER ZONES
FROM TO DESCRIMON
Well Contractor Name
Warren D. Eadus 3 ft 5 ft md. slid (fill)
rcE� I) 5 ft 8 ft fn sand well sorted
NC Well Contractor Certification Number 15.OUTER CASING forulti-cased wells OR LINER a licable
3410-B Y 2�21 FROM m
TO DIAMETER THICKNESS MATERIAL
L 1 ft ft in.
Company Name
�tr$5�I1g UtSlt 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: N/A Jgxrniton prc� FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. ,Counlo i:e,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft 3 it 2 in'. 0.10 sch 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
InMonitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation e
19.SAND/GRAVEL PACK if applicable)
-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2 ft 8 ft #2 Sand 1pour
❑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 DESCRH'TIONcolor,hardness soWreck in size,etc.
0 ft 5 ft It brown medium sand fill
4.Date Well(s)Completed. 04/20/21 well ID#AST-MW-2 5 ft 8 ft grey fine sands
5a.Well Location: ft ft
Pirates Cove Marina N/A ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
Tightline Holdings, LLC/ZKT, LLC ft ft
Physical Address,City,and Zip ft ft
2000 Sailfish Drive Manteo 27954 Dare 21.REMARKS
County Parcel Identification No.(PIM Bentonite 1-2 feet bgs.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Cerdf.ca' n:
35.8949 N -75.6413 W
6.Is(are)the well(s): MPermanent or ❑Temporary SifLArc o ertified We tractor' 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 ItNo 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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:w^ 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 ifdierent(example-3@200'and 2@I001
e3.1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018