GW1--05896_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 apQIlcable)
2370-A FROM TO , DIAMETER THICKNESS I 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
pp y FROM TO DIAMETER SIAT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 75 ft. 10 ff. 2 in. .010 sch 40 avc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Cotnmercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 3 ft. Bentonite poured from surface
Monitoring 0 Recovery 3' ft. 0 ft' Cement poured from surface
Injection Well: ft ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage 75 ft. 6' fL silica sand(#2) tremie
Experimental Technology 13 Subsidence Control ft. ft
Geothermal(Closed Loop) 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,gain size,etc.)
0 ft. 2. fL Topsoil
08-28-2024 MW-02 ft. ft t ,
4.Date Well(s)Completed: Well II)# 2' 8 \Grey sand w/trace of day L
'
5a.Well Location: 8 f. 28 ft' Grey sand
t 4,.. 4
rs
Robert Wynn 28 ft. 48 ft. Grey sand w/trace of day / £ 10(
.,,...� 0 j I/�
Facility/Owner Name Facility if*(if applicable) 48 ft' 58 ft. Grey silty sand WI shell ,,t't•r,. �^ i'l�Q
Ponderosa Rd., 58 ft. 68 ft. Grey sandy clay w/shell Q'•S-i_G
Physical Address,City,and Zip 68 ft• 75 ft- Fine grey sand w/shell 3 1 ,,,`y
Camden Co. 21.REMARKS i
County Parcel Identification No.(PIN) Completed w/4"standing riser cover&2'x 2'concrete pad.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one►at/long is sufficient) 22.Certifi a
36.545200 N -76.324161 w
09-10-2024
6.Is(are)the well(s)0Permanent or atemporarc Si tore 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: fixes or IC No with 15A NCAC 02C.0100 or 15A 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#2/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: 75 (R-) 24a. For AU 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: 7.5 on.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
mud rotary 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&Iniection 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