GW1-2022-06907_Well Construction - GW1_20220718

Prinf�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 ft. ft.
ft. ft.
NC Well Contractor Certification Number l
15.OUTER CASING for multi cas¢d;wells OR LINER if a` licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 2 1, in SCH 40 PVC
Company Name 16.INNERCASING 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 rL 8 ft, 2 in. SCh 40 PVC
3.Well Use(check well use): ft. ft. I n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER Y SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 8 ft- 18 ft- 2 10' .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT.
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 0.5 ft- Cementlaenionite Mbt Hand pour(outer casing)
x Monitoring Recovery 0.5 ft. 6 ft* CementlaerdontteMix Hand pour
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK(if a lichble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [:3Stormwater Drainage 6 ft 18 It. #2 Filter Sand Hand pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach addititinal sheets if necessa`
Geothermal Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soff/mck type.gnin she,etc
0 ft. 6 ft- Tan sand
4.Date Well(s)Completed:6/13/22 well ID#MW 2 12 ft- 16 ft- Brown sand
5a.Well Location: 16 ft• 18 ft* Gray-sand
Wast Fort Macon Road, LLC ft. ft.
-6 I F�3
Facility/Owner Name Facility iD#(if applicable) ft. t f n .`"
1620 Salter Path Road ft. ft.
Physical Address,City,and Zip ft. ft.
Carteret 6334.05.17.5958000 21.REMARKS'
County Parcel Identification No.(PIN) „ r r,��Stl`�lpZ�l I J-NL91Jl is
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3441 18.90 N 76 53 56.86 W
6.Is(are)the wells)fDPermanent or OTemporary Signature of Certified Well Contra for to
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: DYes or lNo 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
9.Total well depth below land surface: 18 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ti d fferent(example-3(200'and 2@100') construction to the following:
10.Static water level below top of casing:4.33 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
8 1/4
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Hollow Stem Aug er 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&Infection Wells: In addition to sending the form to
the address(es) above, also submits 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