GW1-2021-02448_Well Construction - GW1_20210811

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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 I DESCRIPTION
(NCWC) 3470-A ft. 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 THICKINESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. ft• 12 `• Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 13 & ft. 23 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) LOResidential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
LTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 11 & ceme,,m ntonite Mix Hand pour(outer casing)
-X Monitoring Recovery - & ft. CemenHaer onBe"Mix -Hand pour(inner casing)_
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 11 ft. 23 ft. #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock rain s' eta
0 ft. 5 ft. Brown slightly clayey sand'
4.Date Well(s)Completed:7/1 5/2021 Well ID#MW-1 5 ft. 10 ft. Reddish brown fine and medium sand
5a.Well Location: to fa 28 ft• Light gray fine and medium sand
Tar Heel Middle School 28 ft. 30 ft- Dark gray clay
Facility/Owner Name Facility]D#(if applicable)
ft. ft.
15888 Highway 87, Tar Heel NC ft. ft.
Physical Address,City,and Zip ft. ft.
Bladen County 24615 21.REMARKs
County Parcel Identification No.(PIN) g 'n Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4 Eml,g, S'edc)n
(ifwell field,one tat/long is sufficient) 22.C 'fication: e
34 44' 19.76" N -78 47' 39.64" W fl
&a- 8/5/2021
6.Is(are)the well(s)ox Permanent or Temporary S ibdftKof&&KeJWeltrXn0aczr Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JNo 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 page to provide additional well site details or well
construction,only I 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 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12.65 (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 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 pushy 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 Sunoly&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 Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016