GW1-2022-10688_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
7-
1.Well Contractor Information:
Matt Wiggins 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
(NCWC) 4366-A ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi cased,wells OR LWER if a licable
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS RATERIAL
List all applicable well construction permits(i.e.UIC,County,State,{Parlance,etc) +3 ft. 5 ft- 2 in- Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FRO i SCREEN TO DIA1 WrER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 5 ft. 20 ft. 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18-GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
_ Non-Water-up __ e 0.0 ft. 3 ft. Cement/Benlonite Mix Hand pour(outer casing)
X Monitoring Recovery ft. ft, CementiBentonRemix Hand pour
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if s licable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 3 ft. 20 ft. #2 Filter Sand Hand pour
Experimental Technology E]Subsidence Control ft. ft.
RGeothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type rain size,etc
0 ft 10 ft. Gray sandy clay
4.Date Well(s)Completed: 11/9/2022 well ID#M W-1 10 ft. 20 ft. Light ra clayey sand
5a.Well Location: ft. ft.
Jacksonville Business Park ft. ft. ',
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 3 h,�ate'�•a ih ?d ..-Lt,.`
177 New Frontier Way Jacksonville NC ft. ft. Dr C 0 L 2022
Physical Address,City,and Zip & ft
Onslow 036286 21.REMARKS
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:
34 47' 33.25" N 77 25' 45.79" w
��� y_ !�J/�/i��n�� 11/17/2022
6.Is(are)the well(s)oPermanent or DTemporary Signature of Certified Well Contract94 Date
By signing this form,I hereby cenfy that the well(s)was(there)constructed in accordance
7.Is this a repair to an existing well: [Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Mown well construction information and explain the nature of the copy of this record has been provided to tine 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 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: 20 (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths y'different(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing:7.23 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 8 1/4 (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: f
(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
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection 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