GW1-2022-06909_Well Construction - GW1_20220718

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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.
NC Well Contractor Certification Number 15..OUTER CASING for mule-cased wells OR LINER ifa Gcable
Mid-Atlantic Drilling, Inc FROM TO DiAD1ETER: THICKNESS MATERIAL
+ ft. ft. 2 1D SCH 40 JPVC
Company Name
`16.INNER CASING OR TUBING cothei•aral closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MAT tIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 & 8 ft. 2 1n' SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN•
Water Supply Well:
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 8 ft- 18 ft' 2 1°' .010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 0.5 ft' Cement/Bentonile Mix an pour(outer casing)
x Monitoring DRecovery 0.5 ft- 6 ft. CementlBentonb mix Hand pour
Injection Well:
ft. ft. ,
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licaible
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL' I EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage 6 It. 18 & #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 DESCRtPIION color,hardness soiV�ock a sac,eta
0 ft. 6 ft. Brown sand
4.Date Well(s)Completed:6/13/22 Well ID#MW 4 6 ft- 18 ft. Gra %sand
5a.Well Location: fa ft.
Wast Fort Macon Road, LLC ft. ft. ill QA
RP»
Facility/Owner Name Facility 1D#(if applicable) ft. ft' , It u_
1620 Salter Path Road ft. ft. 18 9
ft.
Physical Address,City,and Zip ft.
Carteret 6334.05.17.5958000 21.REMARKSrig ",-� ^t
"M JI
County Parcel Identification No.(PIN) 1>1� ''' }�(i��'DryUI•L �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3441 17.91 N 76 53 54.53 We2j6IL Ad
6.Is(are)the well(s)(X Permanent or OTemporary Signature ofCertified Well Contractor 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: [3Yes or rXINo with ISA NCAC 02C.0100 or I5A 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 ifdoerent(example-3@200'and 1@100') construction to the following: }
10.Static water level below top of casing:4'$� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service'enter,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 Surmly&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-I North Carolina Department of Environmental Quality-Division of Water Resoureei Revised 2-22-2016