GW1-2021-03091_Well Construction - GW1_20210622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
D T Chalmers, Jr. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4146A N/A It- ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
CATLIN Engineers & Scientists FROM TO DIAMETER THICI4VESS MATERIAL
0 ft. 20.5 ft 2 SCH 40 PVC
Company Name
A 16.INNER CASING OR TUBING eothermal dosed-loop)
N
2.Well Construction Permit#: " -/- - FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) fL fL in.
3.Well Use(check well use): fL fc in.
17.SCREEN , SLOT SIZE T
Water Supply Well: FROM TO DIAMETER :.' HICKNESS MATERIAL
Agricultural 13Municipal/Public 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 E3Residential Water Supply(shared) Is.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 18.5 fL Neat cement Surface pour
x Monitoring DRecovery ft. ft.
Injection Well:
ft f4
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 18.5 ft 30.5 ft Sand Surface pour
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUmck rain size,etc.
ft. ft No samples taken.
4.Date Well(s)Completed:4/29/2021 Nell ID#52GW28R ft. ft.
ft. ft.
5a.Well Location:
MCAS Cherry Point N/A fL ft C .Nil
Facility/Owner Name Facility ID#(if applicable) ft. ft. �+
Bldg 133 - A Street, MCAS Cherry Point, NC ft. fL ► �y �,
Physical Address,City,and Zip ft ft n o f-sln. 01i1�
Craven N/A 21.REMARKS infnrlroit49
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22.Certification:
34.89360619 N -76.89820568 W 6/3/2021
6.Is(are)the well(s)oPermanent or OTemporary 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: 13Yes or JqNo with ISA NCAC 02C.0100 or i5A 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 n21 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 1@100') construction to the following:
10.Static water level below top of casing:5 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 (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 SunDly& Iniectiom.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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