GW1-2021-00471_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 1 14.WATER ZONES
d,11( +nnedu[Name tlo Dl To fit s(RIPTION
It. fl.
2370-A
D. ! ft
]C Nell('000-anor C'enilicuoon Nunth°r 15.OUTER CASING for mull ul welB OR LINER ih livable
Fishburne Drilling Inc. rROM 10 DIAN It,:R 5( 'kSI MATFR14L
ft. ft. in.
Company\era. 16.INNER CASING OR
hermdwmR-
2.Well Construction Permit imM To oo
MATFRIAL
t in all uYplir nhfe hell rnrrnrmnnn permit.11.- GlC',Cuunn;Stere, I'arinnre,e[.1 R. ❑. Id.
3.Well Use(check well use): ft. h. in.
1: 17.SCREEN
Water Supply�i`el
FROM to DIAMETER fi1,01SIZF IHUXNFSS ]IAITRIAL
Afpicuhwal Municipal public 10 ft 25 fL 2 in. 010 sch.
Geothermal(I Ieating'Cooling Supply) OResidential'Paler Supply(single) ft. ft. is
Industrial'Comme cial [3Rcsidential%kater Supply(sharcd) 18.GROUT
Irroiation FROM TD MATERfAI. EMPLACEMENT METHOD&ANIOL NT
Son-Water Supply Well: 15 f. 1.0 fE pontonite poured from surface
Monitoring Rtcnverc 1.0 f. OB ft Cement poured from surface
Injection Nell:
h. ft.
Aquifer Recharge Groundwater Remcdiation
19.SAND/GRAVEL PACK rfa Iinhle
Aquifer Storage and Recovery ®Salinity Banner FROM to NAI'ERIAI. FNIPLACE.MENTME'rxoD
Arc,fer Teti ❑Stornwater Drainage 10 ft. 15 it. I #2firr,sand nemied through auger
Fxperin-cntal Technology QSuhsidcnce Control H. ft.
Geothermal(Closed Loop) Officer 20.DRILLING LOG taffiab additional sheets if necessary)
Geothermal(Hcatin•Coolin•Return) Other(explain under 421 Remarks) FROMI To DESCRIPTION(color,haphov."thork ope,goon Ad,et,)
0 it. 0.5 ft. gravel
4.Date Well(s)Completed: 01-11-2021 Well ID#MW-3 05 rt• a n. grey-crown day wl or9ades
5a."'ell Location: ft. 10 ft. grey fine sand
ACADEMI Training Facility ft. ft.
1,aPub}'A.rner Name rxdliry lDn of applmaHO
850 Puddin Ridge Rd., Moyock, NC. ft. ft.
Phc6cal Addmss.C1ty-add7lp ft. ft.
Currltuck 1 21.REMARKS
Coumy parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
unmet]Held.nnc tat lorg is suilieien 1 22.Cent iflMft
36.461797 N -76.202597 W, �
-f 01-13-2021
b.Is(are)the is ell(s)o Permanent or ❑I'Femporarc Siunumrc nrCemfird N' IIContracmr D",
HI ,terrine thix Inrnt l hrrehr<rrrfli rh. rhr �elhsl n s n�rre/....aruertd I..nrr..rduso
7.Is this a repair to an existing well: ElYes or E)No rah I5d V 4C n.7C.0100...-1,A A'CdC _C I,,WeII Gmcnverlr...S lurde mid Ad a
(tth 1 '.till 1At f f .. C a 1 eply us ul ,, n/tic ,n,( I ordha.h l.nriJ.-do n 1/ .net
11141 "Id" I"r,nk weir n ) die hack u/of,I...m.
23.Site diagram or additional well details:
S,For Geuprobe/DPT or Closed-Loop oop Geothermal Wells hating the same �on 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 construction details. You may also attach additional pages ifnecessary.
drilled: SUBMIT"LAL INS-TRU'CTIONS
9.Total well depth below land surface. 10 (hy1 24a. For All Wells: Submit this Conn within 30 days of completion of well
Pnr nudelple arllr le,alldVIh,�Idll tr-nmyle $.'0/('and 2Gpinlh] 1 -
1) 2Uc construction to the following'
10.Slade water level below lop of casing: F (ft.) Division of Water Resources,Information Processing Cnit.
Unmet Intl is chore eurlge.un - 1617 Mail Sees ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (ill.) 24b. For Inieetion Wells: In addition to sending the form to the address in 24a
Auger abov also submit one copy of this form within 30 days of completion of well
12.Well construction method: e conswcGon to the following'.
I ie aoga-romrv,ca61c.direct push.eta-i
Division of Water Resources,I aderground Injection Control Program,
FOR W'A"I ER SUPPLY W'F.LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) Method of test: 24c. For Water Supply& Inieetion Well s: In addition to sending the form to
the addressles) ahovc. 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 construclad.
Fonn(A%-1 Nonh Carolina Dcparon nt of Fmimnnncnml Quality-Drcision of Wamr Rcsourcos Rcviod2-22-?tl1h