GW1-2023-02349_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.
2370-A FL
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muhitased wells OR LINER if a livable
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
7 ft. 0 5 ft. 2 in. sCh. 40
Company Name 16.INNER CASING OR TUBING eother al 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. ft. in.
Water Supply Well: 1F7R.M REEN O DIAMETER SLOT SIZE THICKNESS I MATERIAL
[]Agricultural ❑Municipal/Public 17 ft. 7 ft. 2 in- .010 sch.40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weill: 5 r` 3 r` bentonite tremie
InMonitoring ❑Recovery 3 ft. 1 rt. grout tremie
Injection Well:
ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if■ livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 17 r` 5 r` #2 silica sand tremie
❑Experimental Technology []Subsidence Control ft. n.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilIrmit typc rain size,etc.)
0 ft- 5 r`• Topsoil
4.Date WeU(s)Completed: 03-20-2023 Well ID#W-7 .5 r` 6 r` Brown sandy clay
5a.Well Location: 6 r` 17 r`. Tan sand
Adam Heinrich
Facility/Owner Name Facility HO(if applicable) ft. rt.
Sandy Point Rd. ft. ft.
Physical Address,Cite.and Zip
Chowan 783300124627 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific o .
36.012252 N -76.519349 W 3/23/2023
6.Is(are)the weU(s): InPermanent or ❑Temporary Signature ofC;rti Well Cormactor Date
By signing this form,I hereby certify 1 e wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I`JNo I5A NCAC 02C.0100 or 1 SA NCAC 0 C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 WeUs 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: 17 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 200'and 2@1001
10.Static water level below top of casing: 8.8 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Hollow stem auger 12.Well construction method: 9 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinp 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

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