GW1-2022-10689_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 1
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 4366-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +3 ft. 5 ft- 2 1O SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public 5 ft. 20 ft. 2 1n. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
- _ on_WaterSupply-Well:___ __ 0.0 ft. 3 ft. Cement/Bentonitemix Hand pour(outer casing)
X Monitoring Recovery ft. ft. Cementlaentonhe mtx Hand pour
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 3 ft. 20 ft. #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. ft.
RGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soiUrocke, rain size,etc.
0 ft. 10 ft• Gray sandy clay
4.Date Well(s)Completed: 11/9/2022 Well ID#M W-3 10 ft* 20 ft- Light gray clayey sand
5a.Well Location: ft. ft.
Jacksonville Business Park ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �``�, e i? I!-A .
�-
177 New Frontier Way Jacksonville NC ft. ft. _ 3 16 9029
Physical Address,City,and Zip & ft.
OnSlow 036286 21.REMARKS
Jt
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' 34.43" N 77 25' 49.10" W 11/17/2022
6.Is(are)the well(s)ox Permanent or DTemporary Signature o Certified Well Contactor- 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 x)No with 1SA 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 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 ry'diQerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:7.67 (ft) Division of Water Resources,Information Processing Unit,
lfwater 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 font 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
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 t i 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