GW1--01069_Well Construction - GW1_20240212

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
William M Wiggins 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
(NCWC) 3470-A ft. ft.
ft. ft. ! '
NC Well Contractor CertificationNumber 15.OUTER CASING(for multi-cased wells)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 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. i in.
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 12 ff. 22 ft. 2 ln' .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT.. •s
Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6 ft. Cement Hand pour(outer casing)
•
K Monitoring DRecovery 6 ft. 10 it Bentonite Hand pour
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 10 ft. 22 ft. #2 Filter Sand Hand pour
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks)
0 ft• 8 ft. Tan'sand
4.Date Well(s)Completed:1/17/24 Well 1D#MW-5 8 ft' 14 It Gray tan sand
5a.Well Location: 14 ft. 22 ft' Tan'sand
Bellicourt RV Park ft. ft. x
Facility/Owner Name Facility 1D#(if applicable) ft. ft. ; e
1124 W. Firetower Road ft. ft. rtri 1 2 2024
Physical Address,City,and Zip ft. ft. inforiria:ir•i1 Psr:• w-;L.14
Carteret 5376.01.27.4566000 21.REMARKS ' ffl'Ca:.'^t3
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 CAjiii10/474.
rtification:
34 44' 49.10" N 77 5' 55.09" W
2/8/2024
6.Is(are)the well(s) '(x Permanent or QlTemporaryre of Certified Well Contractors*hip<
Date
_ By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IYes orDNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Oils is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided io'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: 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 2Q100') 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 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 Supply&Ini I t on 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.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1I