GW1--01062_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATERZONES -
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A f ft
ft.. ft..
NC Well Contractor Certification Number Inc15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Mid-Atlantic Drilling, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name + ft. ft. 2 ! ►n• SCH 40 PVC
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) +3 ft. 12 ft. 2 in. 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 DMunicipal/Public 12 ft. 22 ft. 2 in. .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential 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• 6 ft• Cement Hand pour(outer casing)
X Monitoring DRecovery 6 ft. 10 ft• Bentonite Hand pour
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 10 ft. 22 ft• #2 Filter Sand Hand pour
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.,DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type.aralo size,etc.)
( g/ g Other(explain under#21 Remarks)
0 ft• 8 ft• Tan sand
•
4.Date Well(s)Completed:1/17/24 WellID#MW-4 a ft. 14 ft. Gray tan sand.
5a.Well Location: 14 ft• 22 ft' Tansand
Bellicourt RV Park ft. ft. .- -- MI-'
Facility/Owner Name Facility ID#(if applicable)
ft. ft. I I.iL.t/L.f. l/ ;..r
1124 W. Firetower Road ft. ft. FEB 1 2 2024
Physical Address,City,and Zip ft. ft.
Carteret 5376.01.27.4566000 21.REMARKS ittm+'^-'UF''''';':; '
F ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.ors C�rtiification:
34 44' 49.10" N 77 5' 55.09" W ' Ui�//'� 2/8/2024
6.Is(are)the well !Xs) Permanent or I Temp ry Signature of/CCeyrtified Well Contractor ai4A*�� Date
By signing this form,I hereby certifil that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or INo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards•and that a
!Phis 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 1i21 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: 22 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
•
10.Static water level below top of casing:7.98 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 1/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Hollow Stem Auger above, also submit one copy oftthis form within 30 days of completion of well
12.Well construction method: construction to the following: i 1
(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&Iniection 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
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