GW1-2022-06910_Well Construction - GW1_20220718

r 'Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Matt Wiggins '14.WATERZONES }; i
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 4366-A ft. ft.
ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING for multi�cased:wells OR LINER if a 'licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER• THICKNESS MATERIAL
+ ft. ft. 2 is SCH 40 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)' _
2.Well Construction Permit#: FROM To DIAMETER THICKNESS bATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. 8 ft. 2 1 , Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DILlltI9M SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 10 ft- 20 ft' 2 in- 010 SCh 40 PVC
-NIrrigation
Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in:
IndustriaVCommercial Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 0.5 ft. CemenMentonlle Mix Hand pour(outer casing)
x Monitoring EIRecovery 0.5 fa 8 ft, CementlBentonite Mix Hand pour
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL?PACK(if applici ible)
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL I. I EMPLACEMENT METHOD
:)Aquifer Test DStormwater Drainage 8 ft. 20 fa #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. ft. j
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM I To DESCRIPTION color,hardness,soil/rock type,grain sae etc
0 ft. 8 ft- Tan sand
4.Date Well(s)Completed:6/13/22 sell ID#MW 5 8 ft. 20 ft. Gray sand
5a.Well Location: ft ft.
Wast Fort Macon Road, LLC ft. ft.
Facility/Owner Name Facility TD#(if applicable) ft. ft. R
1620 Salter Path Road ft. ft.
Physical Address,City,and Zip ft. ft.
Carteret 6334.05.17.5958000 21.REMARKS
a✓dvr,.
County Parcel Identification No.(PIN)
p
i lI
11'YI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3441 11.81 N 76 53 55.66 !244&_
6.Is(are)the well(s)J Permanent or OTemporary Signature of Certr ed Well Contractor �- Da
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONo 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 erplain 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.
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (fx) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtfferent(example-3(200'and 2(a3100') construction to the following:
10.Static water level below top of casing:6.07 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C enter,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 Aug er 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
139.Yield(gpm) Method of test: 24c.For Water Supply&Injection 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 t i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesl Revised 2-22-2016