GW1--03747_Well Construction - GW1_20240621

IPrint Form
WELL CONSTRUCTION RECORD (GW-1) I or Internal Use Only:
1.Well Contractor Information:
Mike Young 14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name ft. It.
2370-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(N ap livable)
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(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 °Municipal/Public 72 ft* 2 ft 2 in. .010 act.4o PVC
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) h, ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft. 1 ft, chip bentonite poured from surface
Monitoring D Recovery 1 ft. 0.5 ft• cement hand placed
Injection Well: ft. ft.
-
BAquifer Recharge fl(iroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 01 Salinity Barrier FROM To MATERAAI. EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage 12 ft. 2 ft- #2 Silica Sand tremied through augers
Experimental Technology D Subsidence Control ft. ft.
°Geothermal(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) [other(explain under#21 Remarks)
0 ft. 1 ft. Brown sandy silt
4.Date Well(s)Completed: 05 15-2024 Well ID#MW-14 t 5 ft' Tan aayey sand
5a.Well Location: 5 1M 12 ft' Tan silty sand
ACADEMI Training Facility ft ft. LA..
...� '
Facility/Owner Name Facility ID#(if applicable) ft ft. I-
a f l.'' ,- J E D
850 Puddin Ridge Rd., Moyock, NC. 27958 ft. ft. JUN 2 1 2024
Physical Address,City,and Zip ft. ft
Currituck/Camden 21.REMARKS )Dior,.,
'C/ICI;
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.Certific 'on:
36.448300 N -76.199350
05-28-2024
6.Is(are)the well(s)13Permanent or °Temporary Si of Certified Well enactor Date
By signing this form,I It certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EINo with 1SA NCAC 02C.0 or/SA NCAC 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: 12 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if Afferent(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 (hi.) 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&Inflection 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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