GW1-2021-06341_Well Construction - GW1_20210915

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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
4 ft. fL
146A
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
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: N/"A" FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance.etc.) 0 ft. 17 f' 1 2 f; in. 0.010 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER i SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 17 ft. 27 ft. 2 in.j 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft,
Industrial/Commercial E Residential Water Supply(shared) 18.GROUT
_ Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 ft- 15 ft- bent. chips surface pour
x Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_i Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 15 ft- 27 ft• #2 Medium Sand surface pour
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
NGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soi0rock e, min sin,etc.
ft. ft.
4.Date Well(s)Completed:8/23/2021 weu ID#MW-03 ft. fL
ft. ft.
Sa.Well Location:
OmniSource ft. ft. .~'
Facility/Owner Name Facility ID#(if applicable) ft. ft
2830 US-421 , Wilmington, 28401 ft. ft. CEP15 2021
Physical Address,City,and Zip ft. ft. �+ 0 7
New Hanover 21.REMARKSPF
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
34.27828 N -77.9566 W D ���- 9/8/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)iras(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Xi No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 411 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: 27 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dJferent(example-3@200'and 2@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;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& Iniection 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 ito:the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2016