WM0801140_Report_20191125

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: rr'Er^C/�F {{�� r ar-{,1 N2 {q p R
ItCVGitl1.u% If iati r!@rS�tSYY14Y
Mid Atlantic Drilling
Well Connactor Name
Cory T Robison
NC Well Contractor Certification Number
NOV 2 5 2019
(NCWC) 4174 Water (lutll'ty R"i'- onal
( nTitl on.r'••t1011
Company Name wilm111PtOL1 nfflG,
2. Well Construction Permit N: WM0801140
List all applicable well construction permits (t. e. UIC, County, Slate, Variance, etc.)
3. Well Use (check well use):
DAgricultural
OGeothernal (Heating/Cooling Supply)
Olndustrial/Commercial
❑Aquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
OExperimental Technology
DGeothennal(Closed Loop)
4. Date Well(t) Completed: 10/7/19
5a. Well Location:
DMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
CGroundwater Remediation
DSalinity Barrier
OStormwater Drainage
DSubsidence Control
OTmcer
Well IBM GW-1
Facility/Owner Name Facility ID4 (ifappbcable)
2831 Carolina Beach Road, Wilmington, 28411
Physical Address, City, and Zip
New Hanvover
County
06506-008-028-000
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.186623 N-77.93066 W
6. Is(are) the well(s): ❑Permanent or dTemporary
7. Is this a repair to an existlng well: DYes or ONo
If this is a repair fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back ofthis form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: fw, b3W-t mmuah oW�n
9. Total well depth below land surface: 22 (fL)
For multiple use//r flat all depths If dierent (example- 3©100' and 1na,100')
10. Static water level below top of casing: 18.5 (ft)
If water level is above casing, rue "+"
11. Borehole diameter: 2 (in.)
12. Well construction method: Direct Push
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use Only: j { a e
14. WATER ZONES (� 1
FROM I TO DESCRIPTION
ft. I ft..
ft, I ft.
15.OlITER CASING for multi -cased wells OR LINER bap liceble
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING an hermai closed-loo
FROM TO DIAMETER THICKNESS 61AU11L
ft. ft. in.
ft. ft. in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
fL ft. in.
Is. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD &AMOUNT
ft, ft.
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK K l site
FROM TO MATERIAL EMPLAC MENT METHOD
ft. tt.
ft. ft.
20. DRILLING LOG attach additional sheets ifnecrosar
FROM TO DESCRIPTION color, har4nen eaiNaek e, ¢e, efe.
ft. ft.
ft. R.
ftft.
ftft,
tt. ft.
ft, ft.
ft. ft.
21. REMARKS
22. Ce •tifeation:
Si m .f Cm/ e12 � �, eL
hysignigthm/
I hereby certify that the well(s)was(were) constructed in accordance u oh
ISA NCClC 01C .0100 or 15A N('AC 02C.0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(a ld'See Over in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Onen-Loor, Geothermal Return Wells: Copy to the
county environmental has m department of the counTy where mstalle
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells roducin over 100000 GPD: Copy to DWR, CCPCUA
13s. Yield (gpm) Method of test:
Permit Program, 1611 MS , Raleigh, NC 27699-1611
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6.6-2018