GW1-2021-03088_Well Construction - GW1_20210622

int Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
D T Chalmers, Jr. 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name
4146A N/A ft- ft
It. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
CATLIN Engineers & Scientists FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 20.5 ft 1 2 SCH 40 PVC
Company Name
16:-INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: NIA FROM TO DIAMETER I THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft ft in.
3.Well Use(check well use): fa ft in.
Water Supply Well: FROME TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic 20.5 ft 30.5 ft 2 in' 10 SCH 40 PVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft ft. in.,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 18.5 f" Neat cement Surface pour
x'Monitoring DRecovery ft. fa
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage 18.5 ft 30.5 ft. Sand Surface Pour
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soillrock e, rain size,etc.
ft ft No samples taken.
4.Date Well(s)Completed:4/26/2021 Well ID#52GW39R ft ft. a�
5a.Well Location: ft ft
MCAS Cherry Point N/A ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft. J v jy N
Bldg 133 - A Street, MCAS Cherry Point, NC ft ft r lP r, prat s;no
Physical Address,City,and Zip ft R ° " -®� ?V,dC1;Ot
Craven N/A 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lat/long is sufficient) 22.Certification:
34.89372725 N -76.8972619 W 6/3/2021
6.Is(are)the well(s)oPermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or JBNo 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 wet/owner.
repair under 921 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 I 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: 30.5 (ft.
P ) 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 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:$ (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
4
13a.Yield(gpm) Method of test- 24c. For Water Supply& Infection 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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