GW1-2022-08260_Well Construction - GW1_20220428

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
FROM
Well Contractor Name TO DESCRIPTION
ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rfa licable
Fishburne Drilling Inc. FROM TO DIAMETER TH<CIQVEss MATFRIAI.
ft. ft. in.
Company Name 2370A
16.INNER:CASING OR TUBTNG(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 5 ft. 0.5 It. 2 1°' sch.40 PVC
3.Well Use(check well use): ft. ft.17.SC
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public 15 ft. 5 ft- 2 1n, .010 sch.40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft. in
71 Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
17r1 ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 3 ft- 1.5 ft. Bentonite poured from surface
:X Monitoring Recovery 1.5 ft. 0.8 ft. Cement Hand placed
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 15 ft. 3 fL Silica sand Tremied through auger
Experimental Technology 13Subsidence Control fa ft-
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach'additional sheets if oecessa .
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,ffmin arse,etc.
0 ft. 0.5 ft Asphalt
4.Date Well(s)Completed:02-14-2022 Well ID# 0.5 ft. 6.0 ft. Grey/Orange clay
5a.Well Location: 6.0 ft. 8.0 fL Grey/tan clay
Dominion Energy 8.0 ft- 12.0 fL Grey silty clay
Facility/Owner Name Facility ID#(ifapplicable) 12.0 ft. 13.5 fL tan fine to medium sand
304 NC 11 , Ahoskie, NC. 27910 131ff` 156 fL Grey /tan siltyclay
Physical Address,City,and Zip ft. ft.
Hertford 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR2
(if well field,one lat/long is sufficient) 22.Certifica IWTPM
36.346306 N -77.002151 W
?5-2022
6.Is(are)the well(s)oX Permanent or E3Temporary Signa of Certified Well Contractor Date
By signing this form,I hereby certi the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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 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: 15 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11
11.Borehole diameter:8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Hollow stem 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,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&Infection 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016