GW1-2022-10686_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Matt Wiggins 14.WATER ZONES 3
Well Contractor Name FROM ft. TO ft. DESCRIPTION
(NCWC) 4366-A ft. ft.
NC Well Contractor Certification Number 15.ouTER CASING for multi-cased wells UR LINER if a 'licable
Mid-Atlantic Drilling, Inc FROM To DIAMETER TRICKINESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +3 It. 5 ft. 2 in' I Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
0 Agricultural QMunicipal/Public 5 ft. 20 ft, 2 in- .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) T&GROUT
Irrigation FROM TO MATERIAL E1IIPLACE&ENT METHOD&AMOUNT
- - - Non-WaterSupply-We1L---- - - - -0.0--- ft.- 3 -_ft. ._CementleentonHe Mee Hand-pour-(outer-casing)-
----
.,, -Water
Monitoring DRecovery ft. ft, CementlBeltontemix Hand pour
Injection Well:
fr. fr.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACF31ENT AMTHOD
Aquifer Test QStormwaterDrainage 3 ft. 20 ft. #2 Filter Sand Hand pour
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) ElOther(explain under 421 Remarks) I
FROM I To DESCRIPTION color,hardness,soil/rock type rain size,etc
0 ft. 10 ft- Gray sandy clay
4.Date Well(s)Completed: 1 1/9/2022 Well ID#MW'2 10 If, 20 ft. Light gray clayey sand
5a.Well Location: ft. ft.
Jacksonville Business Park ft. ft. _ nm T ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. `� Q. C� 8 V
177 New Frontier Way Jacksonville NC ft. ft. DEC L h
Physical Address,City,and Zip ft. ft.
Onslow 036286 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 47' 33.72If 77 25' 47.43"
N w 11/17/2022 _
6.Is(are)the well(s)OIX Permanent or QTemporary Signature of Certified Well Confirfetor 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: QYes or )No with 15A NCAC 02C.0100 or ISA 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-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:6.15 (ft) Division of Water Resources,Information Processing Unit,
Ifwaier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 1 A (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 Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection 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 io the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016