GW1-2021-07797_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) i For Internal Use Only:
1.Well Contractor Information:
Matt Wiggins 14.WATER ZONES
Well Contractor Name ` ft.\1 20 4 FROM TO DFSCRIP:CION
(NCWC) 4366-A NO ` fLM h,
�) ft.
NC Well Contractor Certification Number '
�t 'ti�,a 1S.OUTER CASING for multi-cased wells OR INER if a licable
Mid-Atlantic Drilling, Inc a, s`" ��'�' ', a' FROM TO DiMfEIER LTHICIINFSS AiATER1Ai
+ ft. ft- 2 SCH 40 JPVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 fa 2 ft 2 in SCh 40 PVC
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic 2 ft. 12 ft, 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, fL
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 0.5 rL Cems"entonite mu Hand pour(outer casing)
x Monitoring Recovery 0_5 ft 2 rL oememlaentonitemtx Hand pour(inner casing)
-Injection-Well:- -- -- - -- -- -- - ---
ft. _ ft. ,
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicabte
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. I EMPLACEMENT METHOD
-;Aquifer Test nStormwater Drainage 2 ft 12 ft #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. fa
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks FROMI TO DESCRIPTION color,hardn soil/rack tyM grain sae,etc
0 ft- 10 ft. Tan fill sand
4.Date Well(s)Completed:10/22/2021 well ID#MW-1 R 10 ft 12 ' Darkaray fine sand with shell frogs.
5a.Well Location: ft. ft.
Showboat Motel ft. ft.
Facility/Owner Name Facility iD#(if applicable) It. ft.
702 Atlantic Beach Causeway 28512 It. ft.
Physical Address,City,and Zip fA ft.
Carteret 638509060835000 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
34 42' 34.24" N 76 44' 12.93" W !
10/27/2020
6.Is(are)the well(s)ox Permanent or OTemporary Signature of Certified Well Contractor 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:- [3Yes or u)No with 15A NCAC 02C.0100 or 15A NCAC 01C.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 921 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: 12 ft 00 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:3.52 (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 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 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 Sunnly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: Amount: completion of well construction 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