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Home My WebLink AboutGW1--00137_Well Construction - GW1_20231228 Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I.Well Contractor Information: Fishburne Drilling Inc. 14.WATER ZONES j Well Contractor Name FROM TO DESCRIPTION ft. ft. Mike Young - ft. It. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable) 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 1 HIC'KNESS 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 DI.-tMETER SLOT SIZE THICKNESS MATERIAL ("Agricultural ()Municipal/Public t5 ft. 5 ft. 2 in. 010 sch.40 PVC ("Geothermal(Heating/Cooling Supply) ("Residential Water Supply(single) ft ft in. Qlndustrial/Commercial ("Residential Water Supply(shared) 18.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 f• concrete hand placed Injection Well: ft. ft. ("Aquifer Recharge ("Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ("Aquifer Storage and Recovery ("Salinity Banter FROM TO MATERIAL EMPI.ACt:MFN7 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 site,etc.) ("Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 15 ft. tan sand 4.Date Well(s)Completed: 11-30-2023 Well ID##5 ft. ft. 5a.Well Location: ft. ft. Town of Nags Head ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. - D' NW Corner of S Croatan & Soundside Rd. ft. ft. l 3 S 202:1 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 ladlong is sufficient) 22.Certific 'on: 35.956510 N -75.625727 W , �,� �LiC "v'' 12-04-2023 6.Is(are)the well(s)OPermanent or ("Temporary Signature of Certified Well Contractor Date By signing this form,1 hereby certify a well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: ("Yes or ONo with 15A NCAC 02C.0100 o►1 SA N 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 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 II.Borehole diameter: 8 (in.) 24b.For Infection 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 13 b.Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Envimmnental Quality-Division of Water Resources Revised 2-22-2016 y .,� *.. ,, may,. ...; tiya‘ t9 � A F" S 1+. .--- . _ , °' `;i Legend Untitled Map ,. Write a description for your map. �Na o s ea o. Gate*., .; .- -.• T,`'.r<,r gip`' _/ \ k ,, • . ..< lit. • - . j, , 1 . , ,-,,' , '.1's,'".,..':, ,,',....,' .- '''.•,:''44- --, ,"','I.' '44•',."^-: ''.' .`„ .: '-)4.1 -, \, OCK r '6 .. t'11e ` ' 1 7•4r rti .riT•• • 'S'174 ` •",}...' z .it V .. ,.1,,, -- . . )n ..-, \ .1.•:.v ' - -: lit. .. 4, . . • . .. , . . ". . ,.. \ e.,. , . 8 , , ,. .,.,„. 1 • -..., . ' ;444 ,,,,, • , '� *''�"~ { aS -1, .'2 , * , . .• •1 t 0 ' 130 Mkt''L f . '3 r rille,+is•Histoc t'fxt_i t • e ,� r n ' . %' t; * l'I'-',.,,,i.,,l,..,,,,1•!..-:1,,.'.,.\‘'-',,,„,„',".,,,, , ,�� > t.',..,,,.;‘-.0.:::..:*'.'4,-.,:'.'::' li...: -.,',. ,,,.‘._,:".:''',,"'le';104'''.''''':„... l'i:,,,,,..,„.1.,..„1'.',,,.:- _ , - • • `Nags Veal Church' - ` • N '6,_ ``® 300 ft