GW1--05895_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Fishburne Drilling Inc. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
Michael Young
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
2370-A 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 MATERI Al.
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 0Municipal/Public 75 ft. 10 ft. 2 in. .010 sch 40 PVC
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft in.
Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 6 ft. 3 ft. Bentonite poured from surface
Monitoring Recovery 3• ft• 0 ft. Cement poured from surface
Injection Well: R. ft.
Aquifer Recharge ()Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATF.RIAI. F.MPI.ACEMENT METHOD
Aquifer Test DStormwater Drainage 75 ft• 6' ft, silica sand(#2) tremie
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. Y ft- Topsoil
08-28-2024 MW-03 ft, rt -, ,
4.Date Well(s)Completed: Well ID# 2" 8 \Grey sand w/trace of day 0(
s,
5a.Well Location: a ft• 28 ft. Grey sand ,� `.
Robert Wynn 28 ft. 48 ft• Grey sand w/trace of clay •i t;f i c ON 4`1
Facility/Owner Name Facility PO(if applicable) 48 ft. 58 ft. D I r)
Grey silty sand w/shell f'
Ponderosa Rd., 58 ft. 68 ft. Grey sandy day w/shell Cs"('8',444,
Physical Address,City,and Zip 68 ft. 75 ft. Fine grey sand w/shell
Camden Co. 21.REMARKS
County Parcel Identification No.(PIN) Completed w/4"standing riser cover&2'x 2'concrete pad.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitica•o :
36.550426 N -76.326634 c
09-10-2024
6.Is(are)the well(s) X0 Permanent or OTemporary Signature of Certified W I Contractor Date
By signing this form,I hereby certify that (s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or gaiNo with 15A NCAC 02C.0100 or 1SA NCAC 00 Well Construction Standards and that a
If this is a repair,Jill 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: 75 (0) 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: 7.5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
mud rotary 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

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