GW1--03753_Well Construction - GW1_20240621

LPrint Form
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
)Fishbume 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.U1C,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 MATERAAI.
Agricultural °Municipal/Public 12 tt• 2 ft. 2 in. 010 sch.40 PVC
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D 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.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery DSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 12 ft. 2 ft. #2 Silica Sand tremied through augers
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [')Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size etc.)
0 ft. 1 ft• Brown sandy sift
4.Date Well(s)Completed:05-14-2024 Well DOMW-08 1 It, 12 ft. Tan sand
ft. ft. �5a.Well Location: ft. ft. f _.`L E i.VE D
ACADEMI Training Facility
Facility/Owner Name Facility lD#(if applicable) ft. ft. J U N 2 1 2024
850 Puddin Ridge Rd., Moyock, NC.27958 ft. ft.
Physical Address,City,and Zipft. ft. Irl(P3r�.tsk+..r-t P-,.!. ..%Um
Ys r i ii t C't1
Currituck/Camden 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/Iong is sufficient) 22.C • ea
36.446078 N -76.174225 Kt
05-28-2024
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ZNo with 1SA NCAC 02C.0100 or 1SA 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 different(example-3 c@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&Infection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016