GW1--00122_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 1 ' i
1.Well Contractor Information:
1
Mike Young --14.WATERZONES 1:.1 _ -.
Well Contractor Name FROM TO DESCRIPTION I
ft. ft. I ,
2370-A ft. ft.
NC Well Contractor Certification Number P` • ` '
=153�OUTER;CASING`(tar:mu"lh-cased�wells)`OR-LINER:;C�fa liable), _ �.
Fishburne Drilling.Inc. FROM TO it .DIAMETER in ! THICKNESS MATERIAL
ft
Company '
.16:1NNERCASINC'ORTUBING(}eottiermalclosed-loop) :r`• ^
2.Well Construction Permit#: _ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable sell construction permits(i.e_U1C,County,State,Variance etc.) it. R. In.
3.Well Use(check well use): ft. it !It
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 10 ft 25 ft• 2 1O o10 sch 40 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft ft In.
Industrial/Commercial E3Residential Water Supply:(shared) ;18.;GROUT ::
Irrigation -- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.5 It. 1.0 ft* bentonite I poured from surface
(Monitoring IDRecovery , t.0 ft 0.8 ft Cement poured from surface
Injection Well: ft. ft
Aquifer Recharge °Groundwater Remediation '
'i19i5ANDIGRAVEL:PACK(i:appIlcahIe)^ -, _
Aquifer Storage and Recovery Salinity Barrier FROM TO. MATERIAL EMPLACEMENTMETHOD
Aquifer Test EpStormwater Drainage 10 ft 1.5 ft. #2 filter sand tremied through auger
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer I 20 DRILLING LOG:OW:elf additional"sheets if uecessan) =;. '-'
_ FROM TO. DESCRIPTION(color,hardness,satllmck type,gran size,etc.)I.
Geothermal(Heating/Cooling Return) -tOther(explain under#21 Remarks) 0, ft. 0.5 ft gravel
4.Date Well(s)Completed -
01-12-2021 WellID#MW-1 0.5 ft. 4 ft grey-biown;daywlorganics .i
5a.Well Location: " ft 1D ft greyflne sand
ACADEMI Training Facility ft. ft. 1' (� ' f"M•-
Facility/Owner Name Facility ID#:(ifapplicable) ft. ft. �t� y
•
850 Puddin Ridge Rd.,Moyock,NC. ft. ft ° L023
ft. ft. , tnf rr--- ',. :i
Physical Address,City,and Zip 71 �r
Currituck _It REMARKS ..- 1:' -._t.)aw r' r n,•. 2 giT...
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat%long is sufficient) 22.Cer
36.461745 N -76.202666 �, .
01-13-2021 .,
6.Is(are)the well(s)JIX Permanent or L®.�Temporary Signature of Certified Well Contractor a
Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I°Yes or X No with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill mitknown well construction information and explain the nature of the copy of this record has been provided to the Well owner.
repair tinder#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;piovide additional well site details or well
construction details. You may also:attach'additional pages if necessary
censttuction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells I '
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 ifd fferent(example-3Q200'and 2(100) construction t0 the following: ,1
10.Static water level below top of casing: (ft.) Division Of Water Resources,Information Processing Unit, i
If water level is above casing,use"+" 1617 Mail Service Ceder;Raleigh,NC 27699-1617 !
1
11.Borehole diameter: 8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program, 1
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceder,Raleigh,NC 27699-1636 I13a.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 1
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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