GW1-2022-10635_Well Construction - GW1_20221128

(Print Form
--. _ .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael Young . -44.WATER ZONES-'
Well Contractor Name FROM TO I DESCRIPTION
ft.23 fL I I
70-A
. h. tL f
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable '
Fishburne Drilling Inc. FROM To DIAMETER TffiCIINESS MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 10 ft. 5 it' 2 in. 010 sch.40 PVC
Geothermal(Heating/Cooling Supply) iDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
Fon-Water
ion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 3' ft. 1.5 It. Bentonite tremied thru auger
oring I Recovery 1.5 ft• 0.5 ft- cement' hand placed from surface
--_-- n-Well:er Recharge [)Groundwater Remediation19.SAND/GRAVEL PACK if a livable er Storage and Recovery I�Salinity Barrier FROM TO MATERIAL EMPLACE51ENr METHOD
Aquifer Test [3Stormwater Drainage 10 it- 3 fL silica sand tremied thru auger
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) IOTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Conlin Return) Mother(ckplain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc)
0 ft. 3- ft, Asphalt
4.Date Well(s)Completed: 10-24-2022 Well ID#MW-1 3" ft. 6- It. Gravel
5a.Well Location: e• ft. 6 ft. Tan sand
P 1�t CXa g ft. 10 fL Grey sand 3 f S A t..
Ourv� a R 3
Facility/Owner Name Facility ID#(if applicable)
It. ft. NOV 2 8 2022
Juncos St. ft. ft
Physical Address,City,and Zip ft. ft
Nags Head, NC 27959 �y+�� 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certificati
35.869334 N -75.575674 W
11-11-2022
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified ell Contractor ! Date
iX
By signing this form,I hereby cert fy that t ivell(s)was(were)constructed in accordance
-- -7.Is this a repair town existing-well:- QYes -or E)No - with 15A NCAC 02C.0100 or 15A NCAC 0 .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 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: 10 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100D construction to the following: I, '
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service C`rater,Raleigh,NC 276994617
11.Borehole diameter: 8.25 (in.) 24b.For Injection 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:
(Le.auger,rotary,cable,direct push,etc.) I 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection,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 tile 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