GW1--01064_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES ,
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A ft. ft.
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ft. ft. j
NC Well Contractor Certification Number Inc15.OUTER.CASING(for multi-cased.wells)OR LINER(if ap licable)
Mid-Atlantic Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
+ ft. ft. 2 ; •,In. SCH 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +3 ft. 12 ft. 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft in.
17.SCREWater Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 12 ft. 22 ft. 2 1n,' .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT . .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 6 ft• Cement Hand pour(outer casing)
x Monitoring [Recovery 6 ft. 10 ft• Bentonite Hand pour
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 10 ft• 22 ft• #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer '20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 it. 8 fa Tan sand
4.Date Well(s)Completed:1/17/24 Well W#M W'2 8 ft. 14 ft• Gray tan sand
5a.Well Location: 14 ft. 22 ft. Tan sand
Bellicourt RV Park ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. E j it,�Fd ltaf•
1124 W. Firetower Road ft. ft. Li
rr I 2
Physical Address,City,and Zip ft. ft. `� 1 I u14
Carteret 5376.01.27.4566000 21.REMARKS II4aaren:'.i.i 7,.1 CtACin ➢
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 44' 49.10" N 77 5' 55.09" W A r 1O.-4i 2/8/2024
6.Is(are)the well(s)Jx Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes orlNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a -
Ifthls 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 thisfotm' 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 I GW-I 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: 22 (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 2(100') construction to the following:
10.Static water level below top of casing:7.98 (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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniel tion 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 the county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesl Revised 2-22-2016
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