GW1--03754_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 closed400p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAI,
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 ()Municipa1/Public 12 ft. 2 ft 2 in. 010 srn.40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1K GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft 1 ft chip bentonite poured from surface
Monitoring DRecovery 1 ft 0.5 cement hand placed
Injection Well: ft ft. -- -
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 12 ft. 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,suibrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
o ft 1 ft. Brown sandy silt
4.Date Well(s)Completed:05-14-2024 Well ID#M W-06 1 ft 12 ft Tan sand
Sa.Well Location: ft. ft.
ACADEMI Training Facility ft. ft. `L`� z�,
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
850 Puddin Ridge Rd., Moyock, NC. 27958 ft. ft. 11!N 9 1 1024
Physical Address,City,and Zip ft ft.
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.Certific
36.451030 -76.197835
NW 05-28-2024
6.Is(are)the well(s)OX Permanent or OTemporary Zofcmbfied Well Contracto Date
By signing this form,1 hereby ce t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or 21INo with ISA NCAC 02C.0100 or IS C 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 constructiondetails. You may also attach additional pages if necessary.
drilled: --- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (fL) 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(§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 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&Injection Wells: In addition to sending the form to
the addresses) 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