GW1-2022-10636_Well Construction - GW1_20221128

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informdim:
Michael Young 14.WATER ZONES
FROM TO OPSCRD'DON
Well Contractor Name
ft. R.
2370-A --
R. R.
NC Well Contractor Certification Number 15.OUTER CASING far e,ultl-need weW OR LINER if a Ocable
Fishbume Drilling Inc. TROM TO DIAMETER THICKNESS MATERIAL.
R. fL is
Company Name 1&INNER CASING OR TUB IN
2.Well Construction Permit#: mom TO DAMETER THICKNESS MATERIAL
List all applicable well conuructtmr to ado h.e.UIC,County,State,Variance,etc) n. I it. In.
3.Well Use(check well use): n' N. In.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 15 BL 10 fL 2 is 010 arm.4o PVC
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) H in,
IndustriaVCommemiil Residential Water Supply(shared) � .
Irrigation 76 'LL
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4 1L Borders trumied lh,u auger
Monitoring Recovery I 0
.5 fL cwnent herd placed horn Raters
Injection Well:
R fL
Aquifer Recharge �Groundweter Remediation
19.SAND/GRTO PACK tier
Aquifer Storage and Recovery �$ilimly Balder iROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13SWrmwater Drainage i6 ft. 6 It silica amst tr mied this auger
Experimental Technology DSubsidrncc Control
Geothermal(Closed Loop) OTrater ...,..,w+LOG atlaeh additional been If Gcuthelmil catin Coolie Return Other(explain under#21 Remarks FaOIN To I DESCRIPTION eobr,haMn wrvrackr .+tier etc.
D ft. 12 n• Tan send
4.fate Well(s)Completed: 10-24-2022 Well lD#MW-3 12 R. 16 it Gmy sand " ^�'" !
Sa.Well Location: ft. a _
N25;s oc'd
It. NOV 2 S 2022
Facility/Owner Name Facility lD#(if appliceble) n' R
Juncos St. a R. DWOv--30G
Physical Address,City,and Zip
R. h.
Nags Head,NC 27959 tLvlv�e n•REMARKS
County Parcel Ide nfication No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iatnoog is sufficient) 22.Certlflc n:
35.869716 N -75.574117 W c
11-11-2022
6.Islam)the well(s)oPermanent or ®Temporary Signane ofCerified Well Contractor Date
By signing this form,I hereby ced,1 that t e x Ifs)xne/were)core tructed in acrordanre
7.Is this a repair to an existing well: OYes or 0No Pita 15A NCAC 02C.0100 err ISA'VC
C. 00 Well Construction Standards and that a
lfthu u a repair,fell out known well consrruction information and explain the nature of the f'af>us record has burr provided m dre owner.
repair under#21 remarks section or on the back ofthic form.
23.Site diagram or additional well details:
8.For Geopmbe/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 (fL) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple%ells list all depths Jdifferent/example-3Q200'and 2®1007 construction to the following:
10.Static water level below top of casing: (R) Division of Water Resources,Information Processing Unit,
If%cater level is abase casing,use"+" 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (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 Mal Service Center,Raleigh,NC 2709-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply& Iniection 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.
Farm GW-1 North Carolina Department of Enviroomental Quality-Division of Water Resources Revised 2-22-2016

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