GW1--03720_Well Construction - GW1_20240621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2370-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Fishburne Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
2 ft. 0.25 ft. 2 in. sch.40 PVC
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(.e.IBC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural f Municipal/Public tz ft. 2 ft. 2 i° oto sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Cotnmercial
g g in.
0 Residential Water Supply(shared) 18 GROUT
Irrigation
Non-Water Supply Well:
_FROM TO MATERIAL F.�tPI.:tCFMENTMETHOD&AMOUNT
2 ft t Ft. in.
bentoiite poured from surface
Monitoring
Injection Well:
[Recovery Recovery ft. 0.5 ff• cement hand placed
ft. ft.
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 t z ff• 2 ft. #2 Silica Sand tremied through augers
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) []Other(explain under#21 Remarks) o rt. t ft- Brown sandy silt
4.Date Well(s)Completed:05-14-2024 Well ID#MW-09 t ff. 12 ft" Tan sand
5a.Well Location: ft. ft. F.L l L_ . V j E
ACADEMI Training Facility ft. ft. )e
Facility/Owner Name Facility ID#(if applicable) ft. ft. J j N 1 20
L T
850 Puddin Ridge Rd., Moyock, NC. 27958 ft. ft. r _�t
hrFocT '4n .
Physical Address,City,and Zip ft. ft. D'tr cl#C.;
Currituck/Camden 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Ce •
36.440225 N -76.178360
05-28-2024
6.Is(are)the well(s)JPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify tha well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with ISA NCAC 02C.0100 or ISA NCA t ' .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 • •II 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: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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: 8.25 (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 Suooly&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016