GW1-2021-03357_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
FROM TO I DESCRIPTION
Well Contractor Name {t it
(NCWC) 3470-A
fL I'
NC Well Contractor Certification Number 15.OUTER CASING for malti ce8ed wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
It. ft. in
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERLAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc) +3 ft. 10 ft. 4 1°' Sch 40 PVC
3.Well Use(check well use): ft ft' in.
Water Supply Well: FROM E TO WAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 10 ft. 20 ft' 2 1n. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R ft. in.
:)Industrial/Commercial [31tesidential Water Supply(shared) 18.GROUT
7_111irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fa 8 ft. cementmentonite Mix i Hand pour(outer casing)
x Monitoring Recovery ft. ft. Cement/Be itoniteMix Hand pour(inner casing)
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)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 Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnea soiUrock tym grain ske,eta
0 ft. 7 ft. orange and gray silty clay
4.Date Well(s)Completed:5/8/2021 Well ID#MW-4 7 ft- 12 ft- orange and red clayey sand
5a.Well Location: 12 ft. 20 ft gray and tan sandy clay
Microgreen Tract ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
Highway 904 Fairmont 28340 ft. ft.
Physical Address,City,and Zip ft. ft.
Robeson 280301006 21.REMARKS
�nl
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �` � �Y�p11
(if well field,one lat/long is sufficient) 2U471,
rtifac
34.410319 N 79.139376 W
5/26/2021
6.Is(are)the well(s)E Permanent or OTemporary Sig%at&oftWfrel r Date
By signing this form,I hereby ci _ that t well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or lNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If ihis is a repair,fill out knows:well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 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 'I
9.Total well depth below land surface: 20 ft 00 24a. For All Wells: Submit this)form within 30 days of completion of well
For multiple wells list al/depths ifdifferent(example-3(200'and 1Q100') construction to the following:
10.Static water level below top of casing:9.99 (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
13s.Yield(gpm) Method of test: 24c.For Water Sunniv&Iniectiol n,Wellsi 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.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016