GW1-2021-00470_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Mike Young 14.WATER TONES
FROM TO DFSCRIPTION
lvdl C'onhedor Name
ft. ft.
2370-A
n. n.
NC Well Comn¢ior(eraficerurn Sumner 15.OUTER CASING for muhFeased wells OR LINERES if a Rpbk
Fishburne Drilling Inc. ROM 0 DIAMETER THICKNS NIA1fRL11
ft. ft, in.
Company Name 16.INNER CASING OR TURING eothermalclosed-bo
2.Well Construction Permit#: FROM TO DL{METF.a 1'HIC'K\ESS MATERIAL
Lim all apph,vhle a,*oonvtrvcrion..i"n if U1C,Cnunn,sm e, I drinm e,urr l R. R, I W.
3.Well Use(check well use): n. ft. In.
Water Suppy Well: 17.SCREEN
FROM TO DIANIETER .SLOT SIZE THICKNESS MATERIAL
Agncultural Municipal.Public 10 IL 2.5 fL 2 in' 010 scn.4o pVo
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) (t ft in.
InduslriaVCommeroial QResidential Water Supply(shared) 19.GROAT
ITT( atlon FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.5 it. 1A f. benterite enured From surface
Monitoring Recoiery 1.0 f. 0.8 IF. m Ceent poured from surface
Injection Well:
rt. 1t.
Aquifer Recharge Groundwater Remediation
1 SAND/GRAVEL PACK B ble
Aquifer Storage and Recovery �$alilTlty Barrier FROM 111 MATERI{h EMPLA('ESIENT METHOD
Aquifer Tcst DSlomiwater Drainage 10 n. t5 ft• a2 filter.,it trimmed through auger
Experimental Technology Subsidence Control ft. f.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG aBsch addidoaal dneb if nesessa
FROM 10 DESCRIM[ON(robr.aardnew.w 11.1, o nun eta.(
Gcothcrtnnl(Hontin•Ctwlin Return) Other(explain under#21 Remarks)
0 ft. 0.5 It• grovel
4.Date Wells)Completed:01122021 Well ID#MW-2 05 ft. 4 ft• grey-emwn day wl organics
5a."'ell Location: ft. 10 fL grey fine sand
ACADEMI Training Facility ft. n'
Facility/Oanet Name Iracility ID9(it applicable) ft. ft.
850 Puddin Ridge Rd., Moyock, NC. rl. «,
Physical Addrnse,City.and Zip ft. ft.
CUrrituck ' 21.REMARKS
County Parcel Identification No WIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
36.4617891avlon, , off)"emi 76.202749 22.Ce,' a
w � � "z 01-13-2021
ze
6.Is(are)the well(s)o Permanent or OTemporan Signature tit(enifiod Well Contractor Date
Nr styning rhi,f ran, l heretic avtilj rhar in00211�
ac nor/ramrrvned in mrurdanrr
7.Is this a repair to an existing well: Yes or ®No ,,,,h 15A NC'AC 01C'.I1100 nr 15A A(AC 02Well 0,n.env,elo,t Sredards and th ita
IfInt,i,a repair,liltnut knmwi„ellannsrn,Cuon intonation and erplain the nnmre ofthe oaln'of J,ie,ecn,d hay heen provided to,he„ -
enmrunder=21,'enimkv section oron the ba,k 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
q
n
9.Total well depth below land surface: 10 ftlZ 4 a. For A11 Wells: Submit this fomt within 30 days of completion) of well
Pm muOiplr n,11,,hoalletmil,adlifferen,,cranple-3(a;200'and 2G�/0o' construction to the following.
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Cnit,
It„a,e.level a ahoce„wing.ir+e"- 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells: In addition to sending the fomt to the address in 24a
Auger above, also submit one copy of this train within 30 days of completion u1'well
12.Well construction method: construction to the tolluwing.
i,e.auger-rotary.cabl,direct inch.etc.,
Uivision of Water Resources,Cnderground Injection Control Program,
FOR W'A'fER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) Method of test: 24c. For Water Suppis'& Injection Wells: In addition to sending the tirtm to
the address(es) above. also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
tram,CW-1 North Carolina Department of Fnvi mmtxntal Qamav-Diyisino of W atcr Resources Revised 2-22-2016