GW1--01066_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 ft. ft. I
ft. ft. I _
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Mid-Atlantic Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name -1' ft. ft. 2 in, 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 'n' SCh 40 PVC
IWell Use(check well use): ft. ft. in.
Water Supply Well: • FR M REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 12 ft. 22 ft. 2 in, .010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R. ft. in.-
Industrial/Commercial [Residential 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 [Recovery 6 ft. 10 ft. Bentonite Hand pour
Injection Well: - --- - ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 StormwaterDrainage io ft• 22 ft• #2 Filter Sand Hand pour
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft, 8 ft. Tan sand
4.Date Well(s)Completed:1/17/24 WellID#MW-8 8 ft. 14 ft' Gray tan sand
5a.Well Location: 14 ft. 22 ft. Tan'sand
Bellicourt RV Park ft. ft. • Fit�.l' :1 t r
Facility/Owner Name Facility IDii(if applicable) ft. ft.
1124 W. Firetower Road ft. ft. Fttl 20�
Physical Address,City,and Zip ft. ft. lit H Z.)int Ntasegir Usilt
49
Carteret 5376.01.27.4566000 21.REMARKS '. r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 2 .Certif cation:
34 44' 49.10" N 77 5' 55.09" W • 2/8/2024
6.Is arc the wells % Permanent or Tem ora i ature of Certified ell Contractor Date
Is(are) () p ry
By signing this form,I hereby certl&that the well(s)was(were)constructed in accordance —
7.Is this a repair to an existing well: EYes or ONo with I5A 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 captain the nature of the cap)of this record has been provided io the well owner.
repair under 121 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 (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 topof 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 of this form within 30 days of completion of well
12.Well construction method: construction to the following: , 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&Iniel tton 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'td 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