GW1--05876_Well Construction - GW1_20241001

IPrint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Fishburne Drilling Inc. 14.WATER ZONES
WellContractorName FROM TO DescRiPTi+>N
ft. ft.
Michael Young
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Beattie)
2370-A FROM TO DIAMETER THICKNESS 1 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMtlnicipal/Public 15 ft. 5 ft. 2 in. 010 sch 40 Pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 13.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft. 2 ft. Bentonite poured from surface
ZMonitoring Recovery 2 ft. 0.5 tt• Cement poured from surface
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applcable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage 15 ft. 3 ft• silica sand(#2) tremie
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
O ft. 4. ft. Topsoil
4.Date Well(s)Completed:09-03-2024 Wellimi
MW-03 4. ft. 4 ft. Brown/tan silty day
5a.Well Location: • ft' S ft Tan/Brown silty day
Fortress Wood Products ft. ft. ' ..„i)
fL ft.
tr 1 20?4
Facility/Owner Name Facility 1D# l'(if applicable) T
889 Foreman Bundy Rd. ft. ft.
Physical Address,City,and Zip
ft. ft. r'i-^?-r I .�a
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 lat./long is sufficient) 22.Certif-fc
36.269707 N -76.320407 N
09-23-2024
6.Is(are)the well(s)OPermanent or ()Temporary Signature of Certified well Contracto Date
By signing this form,I hereby certi at the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or InNo with I SA NCAC 02C.0100 or 1 SA 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-I 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 (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®200'and 2Q100') 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
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 Supply&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