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Home My WebLink AboutGW1--00136_Well Construction - GW1_20231228 Pont Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: _ Fishburne Drilling Inc. 14.WATER ZONES WellContractorName FROM 11) uescHtrno ft. ft. Mike Young ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ucable) 2370A FROM TO DIAMETER THICKNESS NJ 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 OMumicipal/Public 15 ft. 5 ft- 2 in. 010 sch 40 PVC 0 Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in. DIndustriaPCommercial DRe sidential Water Supply(shared) 18.GROUT Il Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 3 ft, 1 ft• chip bentonite tremie aMonitoring D Recovery 1 ft, 0.5 ft' concrete hand placed Injection Well: ft. ft. Aquifer Recharge n Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) Aquifer Storage and Recovery ❑I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD OAquifer Test J Stormwater Drainage 15 ft• 3 ft- #2 silica sand tremled Experimental Technology D Subsidence Control ft. ft. DGeothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) jGeothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) 0 ft. 15 ft. tan sand 4.Date Well(s)Completed: 1-29 2023 Well MI#4 ft. ft. 5a.Well Location: ft. ft. Town of Nags Head ft. ft. Facility/Owner Name Facility lD#(if applicable) ft. ft. 3941 S.Croatan Hwy. ft. ft. DEC 3 S 2023 Physical Address,City,and Zip ft. ft. 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-"(;� on• 35.958278 -75.624768 N �, 12-04-2023 6.Is(are)the well(s)E0Peranent or Temporary Signature of Certified Well Contractor Date nr By signing this form,1 hereby certify that well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or inNo with 1 SA NCAC 02C.0100 or I SA NCA 02C.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 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 (n•) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3 t@200'and 2Qa 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. 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