GW1-2021-00469_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER TONES
FROM TO DESCRIPTION
Well Cumracmr Name
ft. ft.
2370-A
I H. a.
NC Well Contractor Certification Number 15.OUTER CASING for On eased weW OR LINER ifs be,
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUMN CA e,hernial chased
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERUL
I to,If applkiihle urn. ni.nrtcn..i p"aral,ti_e. file',Go mm.State. ISrlan, ell R. f. In.
3.Well Use(check well use): ft. h, in.
IN.
ter Supply Well: 17.SCREEN
FROM T(1 DIAMETER SI-OTSILE THICKNESS MATERIAL
gricultural []Municipal:Public t0 h. P5 ft. p in 010 sch.40 vVC
eothermal(Fleating/Coohng Supply) []Residential Water Supply(single) [t ft In.
ndustriaVCommercial []Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: L5 0• to ft. Ioannina. poured from sodas
Monitoring Recovery LO ft
0.8 f. Cement Ignored from surface
ection Well:
quifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK Ba blequifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPL4CEMENTMETHOD
quifer Test []Stormwaler Drainage10 H• LS ft• Y 2 fiher sane trarntsd Ihrougb auger
xperimental Technology []Subsidence Control ft. R
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG bdit,eh additional sbei if Rece sa
!H(1M TO DESCRIPTION mlor,hard. ."11-1,t run eiz eh.
Gcothernel(Heating/Cooling Rctum) Other(explain under#21 Remarks)
0 ft. 0.5 R• gravel
4.Date Wells)Completed: 01-12-2021 Well ID#MW-1 05 ft. 4 ft• gray-brown day wl onanim
5a.Well Location: ft. 10 ft grey fine sand
ACADEMI Training Facility b. ft.
FacilaylOwnerName Facility lD#(ifapplicable) ft. ft.
850 Puddin Ridge Rd., Moyock, NC. ft. f.
Physical Address.Cit,and zip ft. ft.
CUrr tuck 21.REMARKS
County Parcel Identification No (PIN)
5b.Latitude and longitude in degrees/minute eseconds or decimal degrees:
Iifwellfield,one]at/long is sufficient) 22.CertjGe a
36.461745 11,. -76.202666 W /, Z
01-13-2021
6.Is(are)the well(s) 7g Permanent or []Temporaq sign owre of C'emfied Well C'ovtrad.r Date
Is-
B, signing this f rm,1 hornet, certij, that r e tvel/(e/ nas tome/canatvcted in.....'dance
7.Is this a repair to an existing well: []Yes or ONo with I SA N('AL'02(1.010t1 a-15A N'CAC 07C 0200 Well G.nstre,lion Standards and that a
It in,,is a rrpuir,fill out knoum veil....-mstimt infarmati.n.nd explain the nature f the cape/nr,,,,,d h.,heen pr.sided m the,w/1 m,ner.
repao under=2)remark,section""or the Na.k altho form.
23.Site diagram or additional well details:
8.For Geoprobe/UPT 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 I GW-1 is needed. Indicate TOTAL NUMBER ofwells c sWction details. You may also attach additional pages if necessary.
drilled: 1 1) 'SUBMITFAI.INSTRUCTIONS
G�
9.Total well depth below land surface: 10 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
P'.r multiple wells list all depth,,i,dgiv,m/example-3ar200 and Aaron)') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit
!t ume.letrl is.hove near..as," 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
I I.Borehole diameter: 8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: conswction to the following:
li_e-auger,mmrv,cable.direct push,etc I
Uivision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method oftesC 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.
Fenn GW-I North Carolina Department of Frotimnmental Quality-Division of Water Resources Revised 2-22 2016