GW1-2022-06906_Well Construction - GW1_20220718

a -Print Form"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Matt Wiggins '14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 4366-A n ft.
ft. ft. I I
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
Mid-Atlantic Drilling, Inc FROM TO D'nnh1ETER! THICKNESS 11rATERLIL
+ ft. ft. 2il in. I SCH 40 JPVC
Company Name
16:INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNE s V MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. 8 ft. 2 i in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN P.
FROM TO DL1MErER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 8 ft. 18 ft- 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
Irri ation FROM I TO MATERL L EMPLACEMENT METHOD&AMOUNT
INon-Water Supply Well: 0.0 ft. 0.5 ft. CementlBentonile mix Hand pour(outer casing)
k Monitoring !)Recovery 0•5 ft. 6 ft, Cement/Sentonilemix Hand pour
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL.PACK(if applicable)
'DAquifer Stooge and Recovery [ISalinity Barrier FROM TO bIATEML EDtPLACEMENT METHOD
Aquifer Test DStormwater Drainage 6 IL 18 n• #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. ft.
I
Geothermal(Closed Loop) OTraeer 20.DRILLING LOG attach additional sheets if necessary)
_Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRn'IION color,herdoes soiVmck a rain sae,etc
0 ft- 11 ft- Tan sand
4.Date Well 6/13/22 s)Completed: We11ID#MW 1 12 ft 18 r" Gray sand
ft. ft.
5a.Well Location:
Wast Fort Macon Road, LLC ft. ft. - -p it
Facility/Owner Name Facility iD#(if applicable) ft. ft.
1620 Salter Path Road ft. ft.
Physical Address,City,and Zip ft. ft.
Carteret 6334.05.17.5958000 2LREMARKS
� u•at `i�4vu1,Ri7f i i t�L•L't7vli�(9 J��I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "
(ifwell field,one lat/long is sufficient) 22.Certification:
3441 18.41 N 76 53 54.72 W
6.Is(are)the well(s)(DPermanent or Temporary SigrWt1ie6Jr61rrtiffejWc1I Contractor4afe
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 gNo 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 921 remarks section or on the back ofthis 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: 18 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well r
For multiple wells list all depths ffdffferent(example-3@200'and 2@100') Cons n to th ng:
10.Static water level below top of casing:6.75 (f Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
8 1/4
11.Borehole diameter: (in.) 24b.For Infection Wells: addition to sen mg a orm to a 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 Supply&Iniecti kn Wells: In addition to sending the form to
the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironniental Quality-Division of Water Resources Revised 2-22-2016