GW1--07334_Well Construction - GW1_20231113

(hint Form,._�_�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
William Matthew Wiggins FR WATERZOOM ONES' DESCRIPTIONt
Well Contractor Name
ft. ft. I '
(NCWC) 3470-A
ft. ft.
NC Well Contractor Certification Number 15i.OUTER CASING(for multi-cased ivells),'OR LINER(if ap licable) . '
Mid-Atlantic Drilling, Inc FROM TO DIAMETER I : THICKNESS I MATERIAL.
+ ft. ft. 2 iP• , SCH 40 PVC
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.) 0 ft. 2 ft. 2 m•' SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1F7ROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Publie 2 ft. 12 ft 2
ft 1° 010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ;n,
Industrial/Commercial Residential Water Supply(shared)
' 18.GROUT
Irrigation FROM TO MATERIAL ! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 h• 0.5 ft• Cementteentoniie Mix Hand pour(outer casing)
x Monitoring Injection Well: •
Recovery 0,5 ft. 2 ft• CementlaenlonfleMix Hand pour(inner casing)
ft.- -_ - ft.
Aquifer RechargeGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
Aquifer Storage and Recovery
Aquifer Test
Salinity Barrier FROM To MATERIAL EMPLACEMENT M1IIHOD
DStormwater Drainage 2 ft• 12 ft• #2 Filter Sand Hand pour
Experimental Technology Subsidence Control fa ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional-sheets if necessary) - . _. , .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft.
0 ft. 10 ft. DESCRIPTION(color,hardness,soil/rock type,grainsize,etc.)
4.Date Well(s)Completed:9/05/2023 Well ID#MW 5 10 ft• 12 ft•
5a.Well Location: ft. ft.
SOCOL LLC ft. ft.
T
Facility/Owner Name Facility IDb(if applicable) ft. ft. ''c -,.,' .i V "-._
7617.Carolina Beach RD Wilmington NC ft. ft. NOV 2023
Physical Address,City,and Zip ft ft.
New Hanover R08514-003-005-001 .21.REMARKS •' ,rt_ -, .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'r
(if well field,one latIlong is sufficient) 22.Certi tcation: --4
34 .064845, N -77.897756 W At t n`I I P I k. 9/26/2023
6.Is(are)the well(s)jx Permanent or '[Temporary Signature ofCernfill Contractor / .� Date
By signing this form,I hereby cep*that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes- or-EINo -- - - 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 lr21 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: 12 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 1@100') construction to the following:
10.Static water level below top of casing:3.52 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
8 1/4 i '
11.Borehole diameter: (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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection1 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 to tile county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revisal 2-22-2016