GW1--03756_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 NameFROM 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 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
-
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural QMunicipal/Public 12 ft' 2 ft- 2 in 010 sch.40 PVC
Geothermal(Heating/Cooling Supply) OResidential 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 It. 1 ft. chip bentonite poured Iron,surface
Monitoring 0Recovery 1 ft. 0.5 ft• cement hand placed
Injection Well:
ft. It.
Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 12 ft. 2 It #2 Silica Sand tremied through augers
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ff. 1 ft Brown sandy silt
4.Date Well(s)Completed:05-13-2024 Well IDq MW-05 1 ft- 12 R- Tan sand
5a.Well Location: ft. ft
ACADEMI Training Facility ft ft. __ _ _
Facility/Owner Name Facility ID#(if applicable) ft. B• 1 `,r C_>•1 /L-L../
850 Puddin Ridge Rd., Moyock, NC. 27958 ft. ft.
Physical Address,City,and Zip ft. ft. - J V N 2 1 2024
Currituck/Camden 21.REMARKS
County Parcel Identification No.(PIN) 006C.J iCA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •
36.456526 N -76.199127 wt ' ,/
)' 05-28-2024
6.Is(are)the well(s)ID Permanent or O"I'emporan Si of Certified Well Contractor Date
p� By signing this form,I hereby certify t t th well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ID No with ISA NCAC 02C.0100 or ISA NC 0 .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. 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 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3 ,200'and 1@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 Sum&ly&Injection 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 OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016