GW1--00131_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Fishburne Drilling Inc. 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
Mike Young
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
2370A FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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 DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural QMunicipal/Public 15 ft• 5 ft• 2 i"_ 010 sch 40 PVC
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) fL ft. in,
Qlndustrial/Commercial DResidential Water Supply(shared) 1R GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 1 ft. chip bentonite Iremie
Monitoring ()Recovery 1 ft. 0.5 ft concrete hand placed
Injection Well:
ft. ft.
Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery QSalimty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage 15 ft• s ft. #2 silica sand tremied
Experimental Technology QSubsidence Control ft. ft.
DGeothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 15 ft tan sand
4.Date Well(s)Completed: 12-01-2023 Well m## 12 ft. ft.
5a.Well Location: ft. ft. .-.
Town of Nags Head ft. ft. ..., 1 ,
Facility/Owner Name Facility ID#(if applicable) ft. ft. �j W
8135 S. Old Oregon Inlet Rd. ft. ft. eki
Physical Address,City,and Zip ft. ft.
Dare Co. 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.903526 N -75.594187 W
..------7‘6..... / 12-04-2023
6.Is(are)the well(s) Permanent orTemporary Signature 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: DYes or giNo with 15A NCAC 02C.0100 or 1 SA C 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 (H•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection 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 Suouly&Injection Wells: In addition to sending the form to
the addresses) 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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