GW1--00125_Well Construction - GW1_20231228

Fi':, Pnn F rm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .:`
1.Well Contractor Information:
I r
Mike Young 14iWATERzoNEs; .-' I ".:-.-_,...,1:-.,
FROM TO DESCRIPTION i
- Well-ContractorNeme
ft. ft
2370-A
ft. ft.
NC Well Contractor Certification Number :,15:.OUTERCASING(for;multi=cased,wells)1ORLINER.(Irap'llcable , .
Fishburne Drilling-Inc. FROM TO DIAMETER I I THICKNESS MATERIAL-
ft. ft. iu.i
CompanyName :16:INNERCASING`.ORTUBING:(geotliermalclosed-loop) .. i
2:Well Construction Permit#: _ FROM - . TO DIAMETER 1 , .THICKNESS MATERIAL -
List all applicdble well construction permits 0.e.UIC,Comity State,Yariaaceelc)
ft, ft: le. i
3.Well Use(cheek well use): ft, ft in.
17.:SCBEFN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS ^MATERIAL r
Agricultural QJMunicipallPublic 10 ft- 25 ft- 2 in. ;otp set). PVC
i
Geothermal(Heating/Cooling Supply) Eliesidential Water Supply(single) ft ft. in - :
Industrial/Commercial DResidential Water Supply(shared) " '
Irrigation ., _ FROM. TO MATERIAL ic EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1:5 St- 1.0 ft- bentonite poured from surface ,1
)(Monitoring DRe.covery 1.0 ft 0.8 ft. Cement • poured from surface
Injection Well: ft. ft. '
Aquifer Recharge fGrotindwaterReinediation I
„19:SAND/GRAYEL"PACK'(If appllcable)i :a'- : . , . "-I
Aquifer Storage and Recovery DISalinity Barrier FROM - TO MATERIAL EMPLACEMENT METHOD 1
Aquifer Test. EIStormwaterDrainage 10 ft. 1.5 ft- #2 filter sa •nd' tiemied through auger
__ Experimental Technology QlSubsidence Control ft. ft. ;1
Geothermal,(Closed Loop) ©ITracet .20.•DRII LING tOG'(athtcti addition it sh'dets`if ntte sary :' i
FROM_ TO " DESCRIPTION(color,hardness.smUrocktype,Ernie size,eta) r
Geothermal(Heating/Cooling Return) FlOther(explain under.#21 Remarks)
0 ft: 0.5 ft gravel ,i
4.DateWell(s).Completed:01-11-2021 Well ID#MW-4 08 ft' 4 fL grey-brown Clay w/organics
II
5a.Well Location: ft. 10 ft I
grey fine sand
ACADEMI Training Facility ft. ft
ft. ft i, r•- _
Facility/Owner Name Facility ID#(if applicable) i� e.:_ >.1 „—
850 Puddin Ridge Rd.,Moyock, NC. ft. ft.( V.r`'; I
J,
Physical Address,City,and Zip ft. ft. L. `0�� 11
CUrrituck ,21 REMARKS: -•. -In`-•,
County Petrel Identification No.(PIN) rl,,,_. 1:'•:'"'s,. :),
7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lot/long is sufficient) 22.Certificatio .
36.461594 -76.202605
N W 01-13-2021
6.Is(are)the well(s)]Permanent or Temporary Signature of Certified Wellcontractor Date
By signing this form,I hereby certify that th `ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E-iirk. with 15A NCAC 02C.0100 or ISA NCAC 0 .0200 Well Construction Standards and that a ,i
If this is a repair,fill out(crown well construction information laid explain the nature of the copy of this recordhas been provided to the well owner. I
repair raider#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 provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate.TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS 1,
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 if dfferent(example-3Qa 200'and 2@1001 construction to the following:
i' 1
10.Static water level below top of casing: (ft.) Division'of Water Resources,Information Processing Unit, 1
If water level is above.casing,use"+- 1617 Mail Service Center,:Raleigb,NC 276991617
11.Borehole diameter: 8 (in.) 24b.ForIniection Wells: In addition to sending the form to the address in 24a
Auer above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 9 construction to the following: ,
(i.e.auger,rotary,cable,-direct push,etc.) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent a r,;Raleigh,NC 27699-163611
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(copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county i
where.constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
I ,
i i