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Home My WebLink AboutGW1--00132_Well Construction - GW1_20231228 Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Fishburne Drilling Inc. 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name ft. ft. Mike Young NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable) 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. 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural CIMunicipal/Pubiic 15 ft 5 ft. 2 in. 010 sch.40 PVC Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ff. in. Industrial/Commercial DResidential Water Supply(shared) Is.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 3 ft, 1 R' chip bentonite tremie Monitoring Recovery ft 0.5 ft• concrete hand placed Injection Well: t ft. ft. Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0 Stormwater Drainage 15 ft. 3 ft. #2 silica sand tremied Experimental Technology D Subsidence Control ft. ft. Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft. 15 ft. tan sand 4.Date Well(s)Completed: 12-04-2023 Weil ID## 13 ft. It. 5a.Well Location: ft. ft. Town of Nags Head ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. -- 2 8 8806S Old Oregon Inlet Rd. ft. ft. 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 latflong is sufficient) 22.C,ertif 35.886436 N -75.585139 W, 12-04-2023 Is(are)the wells Permanent or D Tern orary Signs of Certified Well Contractor Date 6 s(a ) O� � P By signing this form,I hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or )No with 1SA NCAC 02C.0100 or ISA 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 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths tfdifferent(example-3@200'and 2(4;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 Injection 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&Injection 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. 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