GW1-2021-03360_Well Construction - GW1_20210603

+ Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: t
i
1.Well Contractor Information:
William M Wiggtns 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A 3 ti�11 ti� t f
NC Well Contractor Certification Number w� �g5§��9 15.OUTER CASING for multi cased wells OR LINER if a Ilcable
Mid-Atlantic Drilling, Inc �t,cnS tC 01\ FROM TO DIAMETER THICKNESS MATERIAL.
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.) +3 f 10 ft. 4 la' Sch 40 PVC
3.Well Use(check well use): fa ft in.
Water Supply Well: FROME TO DIAMETER! SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 10 ft- 20 f 2 1D' .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) t. ft. io
Industrial/Commercial Residential Water Supply(shared) le.GROUT -
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Well: - - 0.0 t. 8 ft- cemenvMertcnneatx-Hand-pour(outer casing)
X Monitoring Recovery ft. ft. Cememieamonaemu� Hand pour(inner casing)
Injection Well: f ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK sf a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OI Stormwater Drainage 8 ft. 20 ft #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. t.
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,soiltmck 'n size,etc
0 ft 6 ft, gray silty clay
4.Date Well(s)Completed:5/8/2021 well ID#MW-7 6 1 12 t tan and gray clay
5a.Well Location: 12 ft 16 t' gray clayey sand
Microgreen Tract 16 f 20 f orange silty sand
Facility/Owner Name Facility ID#(if applicable) ft. f
Highway 904 Fairmont 28340 f ft
Physical Address,City,and Zip & f
Robeson 280301006 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34.408274 N 79.138078 W 5/26/2021
6.Is(are)the well(s)Ex Permanent or Temporary Si Cc ell n c r 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: E)Yes or X®No with 15A NCAC 02C.0100 or 15A NCAC 01C.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#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 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 (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 2@100') construction to the following:
10.Static water level below top of casing: 10.76 (ft.) Division of Water Resources,Information Processing Unit,
lfwarer 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
direct
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,dct push,etc.) �� i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection.Wellk 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 for the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016