GW1-2021-06339_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
D.T. Chalmers, Jr. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4146A
ft. fL �
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
IL ft. � in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) 0 ft- 14 I'L 2 in. 0.010 PVC
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 14 ft. 24 ft- 2 in.y 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) [1 Residential Water Supply(single) ft. ft. in.i
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft- 12 a. bent. chips surface pour
X Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 12 ft- 24 ft. #2 Medium Sand surface pour
_Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM ft. To ft DESCRIPTION color,hardness,soiVrock e, rain size,etc.
-
4.Date Well(s)Completed:8/23/2021 Well ID#MW-01 ft. ft.
ft. ft.
5a.Well Location:
OmniSource ft. ft. t r
Facility/Owner Name Facility ID#(if applicable) ft. ft. ;✓� �„f�..
2830 US-421 , Wilmington, 28401 ft. ft.
Physical Address,City,and Zip ft. f,
New Hanover 21.REMARKS
R seciiOn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34.27874 N -77.95817 W D� / 9/8/2021
6.Is(are)the well(s)ox,Permanent or Temporary 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: ®3 Yes 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 921 remarks section or on the back of this farm.
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-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 24 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if afferent(example-3 rt 00'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
H.S. Augers 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,k 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& 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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