GW1--05871_Well Construction - GW1_20241001

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Fishburne Drilling Inc. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
Michael Young ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licsble)
2370-A FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
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. R. in.
1Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAl.
Agricultural QMunicipal/Public 15 it• 5 it• 2 in. .010 sch4D PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft• 2 rt. Bentonite poured from surface
Monitoring ()Recovery 2 ft• 0.5 h• Cement poured from surface
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery jSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage is ft. 3 ft• silica sand(#2) tremie
Experimental Technology ❑. ubsidence Control ft. R.
Geothermal(Closed Loop) DTracer 20.DRILLING LOC(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type.grain size.etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#2I Remarks) o R. q^ Topsoil
4.Date Well(s)Completed:09-04-2024 Well i[D#MW-08 q. tt. q it
( p Brown/tan silty day _
5a.Well Location: ft. 15 ft' Tan/Brown soy day ' `.' ' --,
ID
Fortress Wood Products ft. fL OC T 0 1 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
A.889 Foreman Bundy Rd. ft. ft. Ir,`�: "'t '."".,r4 tja
-
Physical Address,City,and Zip ft. ft.
Elizabeth City,NC. 21.REMARKS
County Parcel Identification No.(PIN) Completed w/8"flush manhole & 2'x 2'concrete pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/Iong is sufficient) 22.Cer n•
36.270659 N -76.320140 W
i 09-23-2024
6.Is(are)the well(s)0Permanent or ()Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi t t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EINo with/5A NCAC 02C.0100 or 1SA N AC 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: 15 (R•) 24a. For MI 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,
f 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
4.25"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 SuDDIv&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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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LEGEND
1- Site Parcel Boundary
Proposed Soil Boring Location
'k O Proposed Permanent Monitoring Well Location
,, ',1,1-11 ....i t
eJf.et i Powered by E'Jr i Esri Community Maps Contributors.Maxar.M. .
Proposed Sample Location Plan
Fortress Wood Products Property
'>,- 889 Foreman Bundy Road
Es.....cw:i
Elizabeth City, North Carolina 27909 ,,,111111111,•111111111
ECS Proposal No. 49-45550P