GW1--00115_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1..We1l Contractor Information:
r
Michael Young • :a4.WATER'ZONEs
FROM TO DESCRIPTION
Well ContractorNamc ft. ft I '
2370-A ft. ft. 1
f.
NC Well Contractor Certification Number •.15..OUTER CASING(for multi-cased:wells)OR LINER(if ap1PVC
ltcable) -
Fishburne DrillingInc. ROM TO' DIAMETER THICKNESS MATERIAL ..
nc. 2.5 ft. 0.3 ft• 2 in. sch.40
Company Name
'16)1VNERCASINGORTUBING'(geodierntalclosed loop)`::
2.Well Construction Permit#: FROM TO DIAMETER( THICKNESS MATERIAL
List allappiicable xrlf construction permits(i.e.U!C,County,State.Variance,etc.) ft. ft. In.
ft. ft in.
3.Well Use(check well use): -
.17.SCREEN
Water Supply Well: -FRO51 TO. DLAIVIETER :SLOT SIZE THICKNESS .MATERIAL
❑Agriculttual DIvlunicipal/Public 10 ft 2.5 ft 2 in: .010 sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fa 10 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells 5 100,000 GPD FROM 'TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: 2 ft• 1 ft Bentonite Poured from surface
dMonitoring ❑Recovery 1 it' 0.5 ft• Cement, Poured from surface
Injection Well: ft ft
❑Aqujfer Recharge ❑GroundwaterRemediation ,;19 SAND/GRAVEL-PACICfrf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 10 ft 2 ft. #2 Filter sand Tremied through auger
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.-DR1LLINGLOG.(attnch additional`sheets if hecessary).--' •- • • -:. . -
FROM TO DESCRIPTION.(color,hardness.soil/roek type,grain size,etc.)
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft Gravel and sand
4.Date Well(s)Completed: 05-26-2021 Well ID# MW-6 1 it 10 ft• Tan sand,
ft ft i
5a.Well Location:
Academi Training Facility ft. ft. '----
. ft ft. fi
Facility/Owner Name Facility ID'I(if applicable) '''"'11...e.d''-a'.? .;•r.,
850"Puddin Ridge Rd., Moyock, NC 27958 ft. ft: • f)rr ..r M�� �`'W
a� `4M 1'O '
Physical Address,City,and Zip - ft f i / y. .7 8 Z�23
Camden 21:REb1ARKS !,- �l
County Parcel Identification No.(PIN) �'v t.Z;;e 7 t I. .
i 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,melt/lung is sufficient) 22.Certification:
36.461907 N -76.202758 Rr /` 6/17/2021
6.Is(are)'the weil(s): dPermanent or OTemporary
Sigoatur of Certified We I Contractor Date
By signing Ihisforma hereby certify ell t the ell(s)was(were)constructed in accordance with
7..Is this a repair to an existing well: ❑Yes or 19No ISA NCAC 02C.0100 or ISA NCAC 2 200 Well Construction Standards and that a copy
I.I.this is a repay,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
I
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.or-Closed-Ltiop.Geothermal Wells having the same You may use the back of this page.to provide additional well construction info
' construction,only 1 OW-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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiierent(example-3 200'and 2©1009
24a..For All Wells:-Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use+" j
8 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter OIL) Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method: Hollow 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: i
13b.Disinfection type: Amount:
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018