GW1--03759_Well Construction - GW1_20240621

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2370-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
2 ft• 0.25 ft- 2 in" sch.40 PVC
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
0 Agricultural 0Municipal/Public 12 ft. 2 ft• 2 in. 010 sch.40 Pvc
DGeothennal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
9Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft• 1 H. chip bentonite poured from surface
0Monitoring Recovery 1 ft• 0.5 ft• cement hand placed
Injection Well:
ft. ft.
()Aquifer Recharge DGrou ndwater Remediation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 12 ft• 2 ft• #2 Silica Sand tremied through augers
Experimental Technology 13Subsidence Control ft. ft.
QGeothemml(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
®Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock tv.e rain size,etc.)
0 ft. 1 ft. Gravel,sand,and rubber chips
4.Date Well(s)Completed:05-13-2024 Well ID#MW-02 1 ft" 2 ft• Brown silty day
5a.Well Location: 2 ft• 12 ft* tan sand
ti ��
ACADEMI Training Facility ft. t`. �1 i..,; Li
Facility/Owner Name Facility ID#(if applicable) ft. rt.
ft. ft. ��� � 1 2024
850 Puddin Ridge Rd., Moyock, NC.27958
Physical Address,City,and Zip ft. ft. • ... '-yam:_y Ur I
Currituck/Camden 21.REMARKS _ -v
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.Certific On:
36.456681 N -76.197730 W
05-28-2024
Temporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)iPermanent or
By signing this form,I hereby ce th the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or )No with 1SANCAC 02C.0100 or 1SA 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 provide to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 12 (ft) 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: (fit.) 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: 8.25 (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 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016