GW1--00130_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 __
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
Mike Young ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
2370A FROM TO DIAMETER THICKNESS '1 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.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal Public 15 fL 5 ft' 2 is .010 sch.40 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) g. g in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 1 ft. chip bentonite tremle
0 Monitoring °Recovery 1 ft. 0.5 ft. 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 EMPI.ACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 15 fL 3 ft. #2 silica sand tremied
Experimental Technology 0 Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks)
0 ft. 18 ft, tan sand
4.Date Well(s)Completed: 12434-2023 Well ID## 11 ft. ft. r
Sa.Well Location: ft. It. nF C 2 g 2023
Town of Nags Head rt. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
''i/i.7'!"'
5314S 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.Cer' atio :
35.933610 N -75.613963
12-04-2023
6.Is(are)the well(s)OPermanent or Q Temporary Sigrratrue of Cettifie Well Contractor Date
By signing this form,I hereby certify t t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or eNo with 1SA NCAC 02C.0100 or 1SA NCA C.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 t 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 (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(0200'and 2(4;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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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