GW1--01065_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATERZONES
Well Contractor Name FROM ft. TO ft. DESCRIPTION
(NCWC) 3470-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
+ ft. ft. 2 I, 1n. 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 I 1°' 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 0Municipal/Public 12 ft• 22 ft, 2 in, .010 Sch 40 PVC
[Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Ilirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 6 ft• Cement Hand pour(outer casing)
Monitoring 0Recovery 6 ft 10 ft• Bentonite Hand pour
Injection Well:
ft. ft.
Aquifer Recharge EiGroundwater Remediation 19,SAND/GRAVEL PACK(if applicable)'
InAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStormwater Drainage 10 ft. 22 it #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
FROM TO DESCRIPTION(color,hardness,sod/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft. 8 ft. Tan sand
4.Date Well(s)Completed:1/17/24 Well ID#MW-1 8 ft• 14 ft• Gray tan sand
5a.Well Location: 94 ft• 22 ft. Tan sand
Bellicourt RV Park ft. ft. i 7- �a,-�*
Facility/Owner Name' Facility ID#(if applicable) ft. ft. L#tz d' it t
1124 W., Firetower Road ft. , ft. FEU a 2 2024
ft. ft.
Physical Address,City,and Zip • 111fOtir.-;;c�o %;
Carteret 5376.01.27.4566000 21.REMARKS, ' I- ✓uoiism U'?}
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 44' 49.10" N 77 5' 55.09" W 1fied1' 4j1 2/8/2024
6.ls(are)the well(s)Jx Permanent or TemporarySignatureell Contractor / 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 1 SA-NCAC 02C.0100 or 1 SA 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: 22 (ft•) 24a. )For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if difibrent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:7.98 (ft.) Division of Water Resiources,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 Injection 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 i
(i.e.auger,rotary,cable,direct push,etc.) I
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 ti!on 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 constructio i,to 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
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