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Home My WebLink AboutGW1--00140_Well Construction - GW1_20231228 Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Fishbume 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 apQticable) 2370A FROM 71) DIAMETER THICKNESS I 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,Saar.,Variance,etc.) it• ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17.SCREEN pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL OAgricultural °Mlnicipal/Public 15 ft. 5 ft. 4 in. .010 sch.40 PVC °Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. fL in. Olndustrial/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 ft• concrete hand placed Injection Well: ft. rt. Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD °Aquifer Test DStormwater 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) 00ther(explain under#21 Remarks) 0 ft. 15 ft. tan sand 4.Date Well(s)Completed: 11-30-2023 WellID# #6 ft. It. 5a.Well Location: it. rt. Town of Nags Head ft. ft. Facility/Owner Name Facility ID#(if applicable) It. ft. J f NW Corner of S Croatan&Soundside Rd. ft. ft. 2023 Physical Address,City,and Zip ft. it.Dare Co. 21.REMARKS _ County Parcel Identification No.(PIN) 1 513.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: 35.956442 N -75.656818 W _,tea � j( 12-04-2023 6.Is(are)the well(s)DPermanent or cilTemporary Signature oft Certified Well Contractor Date By signing this form,I hereby certify that the we (s)was(were)constructed in accordance 7.Is this a repair to an existing well: °Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0 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#2I 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 (ff•) 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@i00') 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 Iniection 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&Iniection 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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