GW1-2023-01188_Well Construction - GW1_20230127

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William Matthew Wiggins 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 4366-A rj M � ft. ft.
��,�c a F: �_ �� ft. ft.
NC Well Contractor Certification Number I n I (1 ] 15.OUTER CASING for multi-cased!wells OR LINER if a Gcable
Mid-Atlantic Drilling, Inc J N h J FROM TO DIAMETER THIC""fi MATERIAL
}. ft. ft. 2 in SCH 40 PVC
Company Name 1niGra��`I��Pr`'r "SrFi� 'ty:+
;try#Qir�rie.' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS NIATERiAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) 0 ft 2 ft. 2 1O' 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 E]Municipal/Public 2 ft. 12 ft. 2 1n. .010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in•
Industrial/Commercial E]Residential Water Supply(shared) 18.GROUT
_ Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 0.5 ft. CemenVBentonte Mix Hand pour(outer casing)
x Monitoring Recovery 0.6 ft. 2 ft* Cement/BentontleMix Hand pour(inner casing)
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK ifa licable
Aquifer Storage.and Recovery DSalinity Barrier FROM To I hATEMAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 2 ft. 12 ft. #2 Filter Sand Hand pour
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mek type rain size,etc
0 ft. 10 ft.
4.Date Well(s)Completed: 1 1/03/2022 Well ID#MW-2 10 ft. 12 ft.
Sa.Well Location: ft. ft.
SOCOL LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7617 Carolina Beach RD Wilmington NC ft. ft.
Physical Address,City,and Zip ft. ft.
New Hanover R08514-003-006-001 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification'
34 .064845, N -77.897756 W al,W&/)� d 11/17/2023
6.Is(are)the wells)J Permanent or DTemporary Signature of Certified well(Contractor/�_ Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 921 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: 12 ft (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:3.52 (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 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 SunDly&Iniection ells: 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 Resources Revised 2-22-2016