GW1--03752_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: iiiiire.......i..., „
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 ap licable)
Fist 1.1burne Drilling Inc. FROM 'r0 DIAMETER THICKNESS MATERIAL
2 ft. 0.25 fL 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 OMunicipal/Public 12 ft. 2 ft. 2 in. 010 sch.40 PVC
Geothermal(Heating/Cooling Supply) D Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) t .GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT y
Non-Water Supply Well: 2 ft. 1 ft' chip bentonite poured from surface
Monitoring Recovery 1 ft- 0.5 ft• cement hand placed
Injection Well: 1
ft. ft.
Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑I Stormwater Drainage 12 ft• 2 ft. #2 Silica Sand tremied through augers
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)
0 ft. 1 ft• Brown sandy silt
4.Date Well(s)Completed:05-14-2024 Well ID#MW-1 0 1 ft. t2 It' Tan sand
5a.Well Location: it. ft.
ACADEMI Training Facility ft. ft. C. '�F D
ft.
Facility/Owner Name Facility ID#(if applicable) ft. I I I k l n 1 0 n 0 A
850 Puddin Ridge Rd., Moyock, NC. 27958 ft. ft.
Physical Address,City,and Zip ft, ft. yrg! a ts►)
Currituck/Camden 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.Certifies a:
36.443201 N -76.183129 K,
05-28-2024
6.Is(are)the well(s)0 Permanent or 0Temporary Signature ofCerti ed ell Con. Date
By signing this form,1 hereby ce hat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or )No with 15A NCAC 02C.0100 or 15 CAC 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:
S.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([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
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 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016