The URL can be used to link to this page

Home My WebLink AboutGW1--00129_Well Construction - GW1_20231228 Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Fishburne Drilling Inc. 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name It. It. Mike Young ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable) 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(i.e.UIC,County,State,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. In Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural °Municipal/Public 15 ft. 5 fr. 2 in 010 sch.40 PVC °Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in, °Industrial/Commercial DResidential Water Supply(shared) 18.GROUT °Irrigation FROM TO MATERIAL EM PIACEMENT METHOD&AMOUNT Non-Water Supply Well: 3 R' 1 R' chip bentonite tremie 0Monitoring °Recovery 1 R- 0.5 fe• concrete hand placed Injection Well: ft. 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 fL #2 silica sand tremied Experimental Technology °Subsidence Control ft. ft. ()Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) FROM 1 TO DESCRIPTION(color,hardness,soil/rock hype,grain size.etc.) DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 15 ft. tan sand 4.Date Well(s)Completed: 11-30-2023 Well ID## 10 R. ft. 5a.Well Location: ft. ft. '` Town of Nags Head ft. ft. - Jt Facility/Owner Name Facility ID#(if applicable) ft. ft. 5401 S. Croatan Hwy. 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.Certifica' n: 35.933690 N -75.612457 W 12-04-2023 6.Is(are)the well(s)OPermanent or °Temporary Signature ofCertified Well Contractor Date By signing this form,I hereby certify that t 11(s)was(were)constructed in accordance 7.Is this a repair to an existing well: °Yes or miNo with 15A NCAC 02C.0100 or 15A NCAC 0 .0200 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 well owner. 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 necessary. 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-3@200'and 2@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 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 where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 i1INIPIIIP _ 'T°' ': i ' ', '. 9� (°)Ilir Untitled Map K � � g "4. Legend I. Villa•e'Rr•za of Nags Hea. ` Write a description for your map. ',. r t. }: ' \ f Resort4Realtty Outer Banks ,�� ,,o \ ‘\. EP t t r ,, \ �OGtback Steakiiouse,.,t: \ . - ; > 16 144 , _...• \ ,, , ' . '"- , 41 . ' ' :,.„4 '4,...‘,, -'..'.1-.,,,,,t,,./.; •-c.,,' , ".. F le j \ ` ''.. .. Village'Realty-t 4 , ' , ;,,,, , •••-• -:Is i,p,' - rfs• . styCrow-Quilt'• hop' , C F .kl, �Sa t' oast e, l o e Nags H ,L''ol'cy Departme t •v `y Nat. gs eao r- & �escueIr- \`A • '' F + r fz$ .0, 11*' ' : ' ;� ' r {" ' '4'4. -;,- . 1^-'' .'' - . ‘ A ,-. .';'.? . 1,, ' -4.,., '4,.'4!'l-: l'l 'C'A.., ‘,1011 1 ''' ''..A -. ,41.,,-.. fir C a , b y^ f s ' \ ,,,;- , - ' ,45r,A ' ' ' . . S -3S %!, s ,1 %Dot w^k. k •F .4r ' " \.., ,L ::,,' , '''''''''''''; ' i ' •.s 1*...:*!.{:.9:4 i , ;7,-,r,\11::::"\\:,,,:'3::::..,,i:'. ,1'il.::44':,-_':. IL\-,:`,:4,.. '; ', „‘ - .. 500el