GW1--00128_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Fishburne Drilling Inc. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
Mike Young
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable)
2370A FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
ft.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 15 ft. 5 ft 2 in. 010 sch.40 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. - in.
Industrial/Commercial °Residential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 1 ft. chip bentonite tremie
Monitoring °Recovery 1 ft. 0.5 ft. concrete hand placed
Injection Well:
it ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage 15 ft. 3 ft #2 silica sand tremied
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) o ft. 15 ft. tan sand _
4.Date Well(s)Completed: 11-30-2023 Well ID##8 ft. ft.
5a.Well Location: ft. ft. nrr ,w
u .
Town of Nags Head ft. ft. r., 7 8 20?3
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 Deering St. ft. ft.
ft. ft.
Physical Address,City,and Zip
Dare Co. 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies o,
35.951938 N -75.623448 _ r
W 12-04-2023
6.Is(are)the well(s)13Permanent or °Temporar% Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the )was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or )No with ISA NCAC 02C.0100 or ISA NCAC 02 0 I i t Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the • r.
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 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if neceecary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-34200'and 2(a)100') construction to the following:
10.Static water level below top of casing: (ft.) 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
Hollow stem 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: _ 24c.For Water Suouly&Infection 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
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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