GW1-2021-03356_Well Construction - GW1_20210603

IF Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A ft ft.
ft. ft j
NC Well Contractor Certification Number 15.OUTER CASING for maltt�ased welts OR Puma
a licable)
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKINESS MATERIAL
ft. ft. is
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MA TERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) f.3 ft 10 fL 4 1O' SCh 40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply 17.SCREEN
pp y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 10 ft. 20 fQ 2 1°' 1 .010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
)Industrial/commercial DResidential Water Supply(shared) 18.GROUT
h'ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 8 & CememMennn,IHe Mix I Hand pour(outer casing)
X.Monitoring Recovery fL K Cement(Bentonne Mix Hand pour(inner casing)
Injection Well:
fL ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 8 ft- 20 ft. #2 Filter Sand Hand pour
Experimental Technology []Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) _!Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soi0rock tym gmin size,eta
0 fL 7 ft• tan and red sandy clay
4.Date Wells)Completed:5/8/2021 well ID#MW-3 7 fL 20 ft, tan and pink clayey sand
5a.Well Location: ft. fL
Microgreen Tract & ft
Facility/Owner Name Facility TD#(ifapphcable) ft ft. t�tr r
Highway 904 Fairmont 28340 ft. ft.
Physical Address,City,and Zip & ft 1 J
Robeson 280301006 21.REMARKS t
County Parcel Identification No.(PIN)
1l t , 'D�r.�,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
34.411703 N 79.136904 W
, 'dv W "- 5/26/2021
6.Is(are)the well(s)Ex Permanent or []Temporary Sig4fitur4VoftrrdRUVeirCofitrictoi T 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: []Yes or JNo 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#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: 20 ft (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12.55 (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 1/4 (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 Sunoly&IniecdI 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 to'the county health department of the county
where constructed.
Fom GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016