GW1-2022-06912_Well Construction - GW1_20220718

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I'
1.Well Contractor Information:
Matt Wiggins 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
(NCWC) 4366-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi cased,wells OR LINER if a liaable
Mid-Atlantic Drilling' Inc FROM I TO DIAMETER T THICKNESS MATERIAL
+ ft. I ft 2 SCH 40 PVC
Company Name 16.INNER CASING OR TUBING eothemal closed-loop), `
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft 28 ft. 2 i°' Sch 40 PVC
3.Well Use(check well use): 17iSCREEN.
ft it. in.
Water Supply Well: FROM TO DIA11fE1ER: SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 28 ft 38 ft 2 in 1 .010 . Soh 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g• ft. in.
IndustriallCommercial Residential Water Supply(shared) 18.GROUT
IITI ation FROM I TO MATERIAL EMPLACEMENT AMMOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 22 ft• CementBentonite Mix Hand pour(outer casing)
x Monitoring !]Recovery 22 ft 26 ft cemenveenwnfte Mix Hand pour
Injection Well:
fa ft. I,
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK tf a 'liable
Aquifer Storage and Recovery Salinity Barrier FROM To I AATERAAL I II EMPLACEt4'EIM METHOD
Aquifer Test E3Stormwater Drainage 26 ft- 38 ft #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. ft. I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 RemarksIJ
FROM I TO DESCRIPTION color,hardnes soff/mck typa grain sae,eta
0 ft 38 ft. Tan sand
4.Date Well(s)Completed:6/14/22 Well ID#MW 9 ft ft. ��
Sa.Well Location: ft. ft.
Wast Fort Macon Road, LLC ft. % jut 1 Z022
Facility/Owner Name Facility ID#(if applicable) ft. ft
1620 Salter Path Road ft. ft. �, A�;y- T;071,
Physical Address,City,and Zip & ft
Carteret 6334.05.17.5958000 21.REMARKS
County Parcel Identification No.(PIN) I-Re-plae-ed existing well pad
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3441 5.48 N 76 53 52.29 w
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
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: ©X Yes or DNo 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 l 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: 38 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3@200'and 2@100') Construction to the following:
10.Static water level below top of casing:21.66 (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 Iniection 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 Ci nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sumily&Iniection.Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction toi 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