GW1--00123_Well Construction - GW1_20231228

Print Forma '
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Mike Young 1a:WATERzorlEss t;.
Well Contractor Namo FROM ft. TO ft DESCRIPTION
2370-A
ft. ft. I ;
NC Well Contractor Certification Number ::15 OUTERCASING(foe:multi-case`dttvells)OR•LINERIftf'$p livable)- -
Fishbume Drilling Inc. FROM TO DIAMETER I 1 THICKNESS MATERIAL
ft ft, in.i
CompanyName I
':-16INNER-CASING'.ORTUBING(geotliermalclosed400p) t =1- ..
2.Well Construction Permit#: FROM. TO DIAMETER' - THICKNESS MATERIAL '
List all.applicable well construction permits(i.e.WC,County,State,Variance,etc.) B• it. _
3.Well Use(check welruse): ft. ft in. "i
Water Simply Well: 17.'SCREEN :;. . j
pY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public 10 ft 2.5 ft 2 in. i.010 sch.ao PVC
Geothermal(Heating/Cooling Supply) ID Residential Water Supply(single) @. ft in.
lndustrirl/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.5 It. 1.0 ft 'bentonite i, poured frontsurface
X Monitoring QlRecovery 1.0 ft 0.8 ft-. Cement poured from surface
Injection Well:
ft. 0. , I
Aquifer Recharge IDIGroundwater Reinediation
:19:`SAND/GRAVEL TACK(if.applicable):
Aquifer Storage and,Recovery Salinity Barrier FROM - TO. MATERIAL 1 EMPLACEMENT METHOD
j
Aquifer Test DIStormwater Drainage to It 1.5. fL #2 filterSand_, tremied through auger I
Experimental Technology QlSubsidence Control ft. ft
Geothermal(Closed Loop) I©-(Tracer '20:DRILLING LOG(attach.additionalslicets ifnecessary) I t
FROM .TO . DESCRIPTION(color.hardness.solliroek type.grain size,etc.) �i
' `Geothermal(Hcating/Cooling Return) n- Other(explain under#21 Remarks)
0 ft 0.5 ft- gravel i
01-12-2021 MW-2 fc
4.Date Well(s) ft. 4 .
Completed: Well ID# 0.5 grey-brown Gay w/organics .`
5a.Well Location: ° R• 10 ft
grey sand fine
ACADEMI:Training Facility ft. ft
Facility/Owner Name FacilityID# a livable �'
ty (ifPP ) ft ft. rr
850 Puddin Ridge Rd., Moyock, NC. ft. ft -,e >,-' VI y' ...,ri, 'i
Physical ft. ft.t i• DEC t
. Phi lAddi City, 3 g eG23 i
Cllrrltuck 21:.RENIARKS 1
{' Inrcr r. r,n 7r
County ,Parcel Idcntification No.(PIN) CA, •dr�ti.,,:3 r-%i'.i
d Zs,-,...-L7 ,I
56.Latitude and longitude.in deb ees/minutes/seconds or decimal degrees:
(if well field;one lat/long is sufficient) 22.Cer' -
36.461789 N -76.202749 W
01-13-2021
6.Is(are)the well(s)�X Permanent or �ITemporary Sigmturo of Certified Well Contractor Date
By signing this form,1 hereby certify that th well( was(were)constructed in accordance
7.Is this a repair to an existing well: Dies or EjNo with ISA NCAC 02C.0100 or ISA NCAC 02 .020 Well Construction Standards and that a i
If this is a repair,fill oirt/mown well construction information and explain the nature of tire copy of this-record lies been provided to then' veer. '+
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
8.For Geo robe/DPT OrClosed-Lao Geothermal Wells havingthe same You may use the back of this page to provide additional well site details or well
pp attach additional pages if necessary.construction details. You may also a
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells i
drilled: SUBMITTAL INSTRUCTIONS'
t
9.Total well depth below land surface: 10 (f-) 24a. For All Wells: Submit this faun within 30 days of completion of well f
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following: 1
10.Static water level below top of casing: (It) Division.of Water Resources,Information:Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection 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 999
• 12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.) I
Division of Water Resources,Underground Injection-Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
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'loopy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form:OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 1