GW1-2021-02447_Well Construction - GW1_20210811

Print Form.4._�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
(NCWC) 3470-A fL ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedl wells)OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERLAL `
iL ft. in
Company Name 16.INNER CASING OR TUBING "eothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0 ft. ft. 12 in' SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply 17.SCREEN
pp y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural E)MunicipaVPublic 13 & It' 23 in., .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft. in.
:),Industrial/commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 11 fL Cement/Sentonite Mix Hand pour(outer casing)
X Monitoring []Recovery ft. ft- Cement/Be r4tontteMix :Hand pour(inner casing) --
Injection Well: h. ft.
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 11 ft. 23 ft. #2 Filter Sand Hand pour
F7,Experimental Technology D Subsidence Control & ft.
Geothermal(Closed Loop) lTracer 20.DRILLING LOG attach additional sheets if necessary)
F_Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock tyM grain size,etc
0 ft. 5 ft. Brown slightly clayey sand
4.Date Well(s)Completed:7/15/2021 well 1D#MW-3 5 fG 10 & Tan fine and medium sand
5a.Well Location: 10 ft. 15 ft Tan fine and medium sand
Tar Heel Middle School 15 & 23 ft' Light gray fine and medium sand
Facility/Owner Name Facility ID#(if applicable) 23 It- 25 ft Dark gray clay
15888 Highway 87, Tar Heel NC ft.
Physical Address,City,and Zip & ft.
Bladen County 24615 21.REMARKS
County Parcel Identification No.(PIN)
• n Processing tt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R gC
(if well field,one lat/long is sufficient) 22.Cc r
illu
cation:
34 44' 17.70" N -78 47' 40.62" W 8/5/2021
6.1s(are)the well(s)�X Permanent or Temporary S' 'cation"tor
C ctor ate
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or JqNo with 15A NCAC 01C.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
9.Total well depth below land surface: 23 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,Qerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 11.65 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
13s.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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