GW1-2021-03670_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
Well Contractor Name FROM TO DESCRIPTION
&
(NCWC) 3470-A ft.ft, ft. I
NC Well Contractor Certification Number 15.OUTER CASING for mWti cased wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DUIMETER THICIavESS MATERIAL
ft. I i in
Company Name 16.INNER CASING OR TUBING(geothermal closed-looli
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) +3 ft- 10 ft. 4 1 iO' Sch 40 1 PVC
3.Well Use(check well use): fr ft' O1
Water Supply Well: FROM SCREEN TO DLAML7'ER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 10 h• 20 lt. 2 1n. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
:)Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
1iri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 8 ft. CemenuBeiaonite Mix !Hand pour(outer casing)
x Monitoring Recovery ft. It- cememrsentonitemix Hand pour(inner casing)
Injection Well:
ft.Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 8 ft. 20 ft. #2 Filter Sand Hand pour
Experimental Technology OSubsidence Control ft. ft.
EGeothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,grain size,ere
0 ft. 16 ft• gray silty clay
4.Date Well(s)Completed:5/8/2021 Well ID#MW-6 16 rt. 20 1 tan and gray clay
5a.Well Location: ft. ft.
Microgreen Tract ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
Highway 904 Fairmont 28340 fL ft. i 3
Physical Address,City,and Zip f, ft.
Robeson 280301006 21.REMARKS ,io
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.Certif tion:
34.409141 N 79.138602 W 5/26/2021
6.Is(are)the well(s)Ex Permanent or OTemporary Signature ofCerAed Well o trac r Date
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or MNo 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#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
i
9.Total well depth below land surface: 20 ft 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 10.65 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 1/4 (in.) 24b.For Infection 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 pushy etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C`eater,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply&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 toF the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources h Revised 2-22-2016