GW1--00127_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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1..Well Contractor Information:
Mike Young 14.wATER=zoNEs, .:;,.::::[.:.1-- -. - -
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I '
2370-A ,ft. ft.
NC Well Contractor CertiEcationNumber I. -
`15:OUTER.CASING(foi�"uiulti�cased.ivells)'.OR:LINER�Cif no Gcable).:."_ _. ,i
Fishburne Drilling Inc. FROM TO DIAMETER I THICKNESS MATERIAL
ft. ft. iu:
CompanyNamc -
'>16:INNER;CASING'ORTUBING(geothm eral closed-loop) -`
2.Well Construction Permit#: FROM TO DIAMETER 1 ' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State.Variance,etc.) ft. ft, in.
3,Well Use(cheek well use): ft. ft. Iu.
14 SGREEN 11
Water Supply Well: FROM TO. DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 15 ft- 5.0 fL 2 in. M. sch.40 PVC
Geothermal(Heating/Cooling Supply) OIResidential Water Supply(single) ft. ft. in. ,;
Industrial/Commercial °Residential Water Supply(shared) 1s.,GROUT -
Irrigation FROM TO. MATERIAL ' . EMPLACEMENT METHOD&AMOUNT '!
Non-Water Supply Well: 3.0 ft. 1.0 ft• bentonite poured from surface
'X Monitoring Recovery 1.0 ft- 0 it, Cement I poured from surface
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
19i'SAND/GRAVE11PACK(If applcalile)i: }•- '- . -" _
_ Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL ' 1 EMPLACEMENT METHOD
Aquifer Test h°_ StorinwaterDrainage 15 ft• 3.0 ft. #2 filter sand I tremlid through auger .!
Experimental Technology °Subsidence Control ft. ft.
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_20:DRILLING:I:OG(attacli additional slicers if necessary)_Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(Color.hardness.
Geothermal(Heating/Cooling Return) flOthcr(explain under#21 Remarks) solOroetc type grain size etc.)
0 ft• 0.5 ft• gravel 1
1.
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4.Date Well(s)Completed:01-11-2021 Well ID#MW-5 0.5 fL 4 ft* grey-brown day ma organics
r.
5a.Well Location: ° ft• 15 ft grey fine sand }
ACADEMI Training Facility rt. ft. l- ' !
Facility/Owner Name 'Facility ID#(ifapplicable) ft. 'j,__.r ,�ij*... ., )
850 Puddin Ridge Rd., Moyock, NC. ft. rt. D r �, i
4 u nn
Physical Address,City,and Zip ft. ft t t uZ 1
'21:REMARKS _..- :.-. e r,. r
Currituck - 6
Gt•d ;';=,µ..•
, 3(Jr.l I
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi 'I r. I
36.461703 N -76:202808 W .•-� / €
01-13-2021
6.Is(are)the wells) IX Permanent or °Temporary Signature of Certified WellContractor Date
By signing this form,I hereby certify that I e wel s)was(were)'constructed in accordance
7.Is this a repair to an existing well: °Yes or X No with 15A NCAC 02C.0100 or ISA NCAC 0 ;02'0 Well Construction Standards and that a
If this is a repair,fill out known well construction infbnnation and explain the nature of the copy of this record has been provided to the we vner.
repair under#21 rentarlm section or on the back of this form. 23.Site diagram or additional well details: 1
8.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well 1
construction details.
construction,only 1'GW-1 is needed. Indicate TOTAL NUMBER of wells You may also attach'additional pages if necessary. I
drilled: SUBMITTAL-INSTRUCTIONS 1
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9.Total well depth below land surface: if (ft) 24a. For All Wells: Submit this £Orin within 30 days of completion of well
For multiple wells list all depths if different 3@200'and 2Q100) .construction to the following: I
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 16171M1ail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: $ (in-) 24b.For Injection Wells: In addition'ta..sending the form to the address.in 24a
Auger above,also submit one copy of this fdim within 30 days of completion of well
12.Well construction method: constniction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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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 orie copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to th r county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016