GW1--03954_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeff Stewart 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
(NCWC) 2540-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"• SCH 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit N: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) +2.5 ft 8 ft. 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 8 ft. 18 ft. 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft• ft, in.
Industrial/Commercial QResidential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2 ft• Cement Hand pour(outer casing)
x Monitoring ORecovery 2 ft. 6 fL Bentonite Hand pour
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 6 ft• 18 ft. #2 Filter Sand Hand pour
Experimental Technology D Subsidence Control It. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain use,etc.)
0 ft• 13 ft• Gray sand
4.Date Well(s)Completed:5/29/24 Well ID#MW-4 13 ft• 16 ft. Gray sandy clay
5a.Well Location: 18 ft• 18 ft. Gray sand
Figure 8 Yacht Club ft. ft t-,�,-•`,L..I;f L ,
Facility/Owner Name Facility JIM(if applicable) ft. ft.
15 Bridge Road, Wilmington, NC tt. ft. AIL 0 , Z024
Physical Address,City,and Zip ft. ft. Irer.'urT'.rh.i<;i .s---N4:4 L('i
New Hanover R04500-005-001-000 21.REMARKS (W).1:.'tr.:
County Parcel Identification No.(PIN)
5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C c .*In:
34 16' 21.07" N 77 45' 15.50" W 6/19/2024
6.Is(are)the well(s)Ox Permanent or Temporary Si: fie I C vector Date
By SSning this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or ljNo with 15A NCAC 02C.0100 or ISA 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 hack 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 I 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: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 20100') construction to the following:
10.Static water level below top of casing:+7.60 (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 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
13a.Yield(gpm) Method of test: 24c. For Water SuDDIv& 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 construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016