GW1--01063_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information: ;,
William M Wiggins 14.WATER ZONES , ,#''i'
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A ft. ft. 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedivells)OR LINER(if ap licable)
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
+ ft, ft. 2 I in. SCH 40 PVC
Company Name
16;INNER CASING ORTUBING'(geothermal closed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) +3 ft. 12 ft. 2 1i in. 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 OMunicipal/Public 12 ft. 22 ft. 2 i°' .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) •
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 OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 10 ft• 22 ft. #2 Filter Sand Hand pour
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .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,groin size,etc.)
0 ft. 8 ft. Tan sand
4.Date Well(s)Completed:1/17/24 Well ID#MW-3 8 ft. 14 ft' Gray tan sand
5a.Well Location: 14 ft• 22 ft. Tan sand *--
Bellicourt RV Park ft. ft. ;' u L i �1f!° '
Facility/Owner Name Facility ID#(if applicable) ft. ft. t H
1124 W. Firetower Road ft. ft. 2 2024
l ;U , 'a
Physical Address,City,and Zip ft. ft. D c 'c' Ucit
Carteret 5376.01.27.4566000 z1.REMARKS i,
County Parcel Identification No.(PIN) I'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34 44' 49.10" N 77 5' 55.09" W
JJ14+4i4 7l/.'f)rS 2/8/2024
6.Is(are)the well(s) Permanent or l Temporary Signature of Certified Well Contracto Date
:.
By signing this form,I hereby cer 'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo 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#2I remarks section or on the back of thisform. 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 (it) 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 topof casing:7.98
g (ft.) Division of Water Resources,InformatioD 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 Infection Wells: In addition to sending the form to the address in 24a
Hollow Stem Auger above, also submit one copy ofjthis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
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 Sunnlv&Inief tion 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