GW1-2021-03355_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIP,TtON
(NCWC) 3470-A ft•
ft. fL 1
NC Well Contractor Certification Number 15.OUTER CASING for malti�ssed wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DU►METER TffiCIINFSS MATERIAL
& ft. in
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS IMATERiAI.
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) +3 f- 12 ft- 4 in. Sch 40 PVC
3.Well Use(check well use): fa & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic 10 ft- 22 fL 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 10 ft- Cemeni/ae`t00se Mix i Hand pour(outer casing)
x.Monitoring Recovery ft. fL Cementieer-nfleMix Hand pour(inner casing)
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 10 fL 22 ft #2 Filter Sand Hand pour
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal (Heating/Cooling Return) MOther(explain under 421 Remarks) FROM TO DESCRn?TION color,hardness,soiu,ock type,grain size,eta
0 fa 6 ft tan sandy clay
4.Date Well(s)Completed:5R/2021 well ID#MW-2 6 ft 12 ftgray and orange clayey sand
5a.Well Location: 12 fL 19 f orange sand
Microgreen Tract 19 ft 22 ft- pink sandy clay
Facility/Owner Name Facility iD#(if applicable) ft. ft•
R
Highway 904 Fairmont 28340 & ft.
tysical Address,City,and Zip ft. ft a
21.REMARKS 5
c;�p!C
County Parcel Identi5cationNo.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 5/26/2021
6.Is(are)the well(s)EX Permanent or Temporary SigAure6f-Cc;tWdWeliZifntfactoir Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or X)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 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#11 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 pagel,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
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9.Total well depth below land surface: 22 ft (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths tfdijjerent(example-3(a)200'and 2 100') construction to the following:
10.Static water level below top of casing: 13.53 (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 1 A (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 Suonly&Iniecti I n 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 toy the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water ResourcesI Revised 2-22-2016