GW1-2023-02348_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft.
2370-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
5 ft 0.5 2 i sch.40
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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. It in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipabTublic 15 ft. 5 ft 2 i"' .010 sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft g, in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4 f. 2.5 R' bentonite tremie
PJMonitoring ❑Recovery 2.5 ft. 1 fL grout tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 15 ft 4 ft- #2 silica sand tremie
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. .5 Ir. Topsoil
4.Date Well(s)Completed: 03-20-2023 Well ID#W-3 5 ft. 6 ft- Brown sandy clay.
5a.Well Location: 6 ft' 15 ft- Tan sand ,+.'_ a`"1..11i
Adam Heinrich ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1 LJ
Sandy Point Rd. ft. ft
Physical Address,City,and Zip ft. ft C,ll`o'C11-1i'0114
Chowan 783300124627 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certifica n:
36.011645 N -76.521811 W _
3/23/2023
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that he ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or CINo 15A NCAC 02C.0100 or 15A NCAC 02 200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and erplain the nature ofthe ofthis record has been provided to the well owner.
repair under#11 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
L1.9 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 8.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: H OI I OW Stem auger 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018