GW1-2021-03358_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft.
(NCWC) 3470-A ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICL�fESS MATERIAL.
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THIC10"S MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) +3 ft. 10 ft. 4 'O' SCh 40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural E)Municipal/Public 10 ft- 20 ft. 2 in. .010 Sch 40 JPvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Ilffigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 8 ft. CementMentonRe Mix 'Hand pour(outer casing)
X Monitring E3Recovery ft. fa Cementlaentonnemu Hand pour(inner casing)
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PAC K rfa licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage S ft. 20 ft. #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. &
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfmck type,grain size,eta
0 ft. 6 ft. tan sandy clay
4.Date Well(s)Completed:5/8/2021 Well ID#MW-5 6 ft- 12 f" dark 'orange clayey sand
5a.Well Location: 12 ft. 20 ft. ra sand
Microgreen Tract ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. It.
Highway 904 Fairmont 28340 ft. ft.
Physical Address,City,and ZipLIJ
ft fL n
Robeson 280301006 21.REMARKS P. M
J
County Parcel Identification No.(PIN) irC�
�r J- 0 V Y t~
qq
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certificati n•
34.409931 N 79.137677 w 4 5/26/2021
6.ls(are)the well(s)ox Permanent or OTemporary S~fifVAfied WetaKntractor V 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: E]Yes or [9No with 15A NCAC 02C.0100 or 15A 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#11 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 pagelto provide additional well site details or well
construction,only t GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS !k
9.Total well depth below land surface: 20 ft (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 2@100') construction to the following:
10.Static water level below top of casing: 12.13 (ft) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:$ 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 Cp nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suonly&Iniection 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016