GW1--01067_Well Construction - GW1_20240212

-.-...-rvr rrr--1
WELL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES - ='•I
Well Contractor Name FROM TO DESCRIPTION
ft, ft, I
(NCWC) 3470-A
�• ft. I i
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 j :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,eic) +3 ft, 12 ft• 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural , DMunicipal/Public 12 ft. 22 ft. 2 in,' 010
in.j
Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft,
Industrial/Commercial Irrigation
Residential Water Supply(shared) 18.GROUT l".,i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Hand pour(outer casing)
Non-Water Supply Well: 0.0 ft. g ft. Cement
Monitoring Recovery 6 ft. 10 ft. Bentonite Hand pour
Injection Well: --- ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 10 ft• 22 ft• #2 Filter Sand Hand pour
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additl6nal sheets if necessary)
FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft, 8 ft• Tan sand
4.Date Well(s)Completed:1/17/24 Well ID#MW-7 8 ft' 14 ft, Gray tan sand
5a.Well Location: 14 ft, 22 ft• Tan!Sand
Bellicourt RV Park ft. t. "
:, °- , �Facility/Owner Name Facility ID#(if applicable) ft. ft. L L# a V
1124 W. Firetower Road ft. ft. ! ' 1 2 ?Q?'?
Physical Address,City,and Zip ft. ft. 1Aere.4'if7 „
Carteret 5376.01.27.4566000 ,21.REMARKS'' f
a U40
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.Certify/lion:
34 44' 49.10" N 77 5' 55.09" W *PimI 1/r/i �t,� 2/8/2024
6.Is(are)the well(s)jx Permanent or Temporaryof Certified Well Contractor ! l Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance - -
7.Is this a repair to an existing well: EYes or QNo with ISA NCAC 02C.0100 or I5A 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 P21 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 different(example-3Ca 200'and 2@100) construction to the following:
10.Static water level below top of casing:7.98 (ft.) Division of Water Resoources,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.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&Injection 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 constructions to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016