GW1--07332_Well Construction - GW1_20231113

Print Farm .
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-...WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
• i l
William Matthew Wiggins :14.WATERZONES_ 1;;.
Well Contractor Name FROM TO DESCRIPTION
--- _ (NCWC) 3470-A ft. ft
ft. ft. I I
NC.Welt Contractor Certification Number 15.OUTER CASING(for multi-cased'ivells)OR LINER(if ap Iicable) •
Mid-Atlantic Drilling, Inc FROM TO DIAMETER I THICKNESS MATERIAL
Corn an Name + ft. ft. 2 'In. SCH 40 IPVC
P y '16.INNER CASING OR TUBING(geothermal 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 ft. 2 ft- 2 in' Sch 40 PVC
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN ;.
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 5 ft. 15 ft. 2 in', .010 Sch 40 PVC
Geothernial(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT l
Irrigation R• FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 0.5 ft• Cement/Beritonite Mix Hand pour(outer casing)
x Monitoring DRecovery 0.5 ft. 2 ft CementBentonneMix Hand pour(inner casing)
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage 2 ft 15 ft #2 Filter Sand Hand pour
Experimental Technology ElSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness,soil/rock type,grain size,etc.)
0 ft. ft.
4.Date Well(s)Completed:9/25/2023 Well ID#MW-1 ft. ft. ,
5a.Well Location: ft. ft.
ft. ft. •
Facility/Owner Name Facility ID#(if applicable) ft. ft. l- ;
- 7984 Market St Wilmington NC ft. ft. '
Physical Address,City,and Zip '
ft. ft. NOV 1 2023
21.REMARKS ' . '
New Hanover -. J ;,.,
County Parcel Identification No.(PIN) lr ,�• n- - _ �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22..�CCertifiee on
34 . N -77. W v U�1 Avow 10/4/2023
- 6.Is(are)the well(s))Ix Permanent or 'Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert{fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No 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: 15ft (ft•) 24a. For All Wells: Submit thisiform within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a(200'and 2@100') construction to the following:
I
10.Static water level below top of casing: (ft.) Division of Water Resoulrces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 114 (in.) 24h.For Injection 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 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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016