GW1-2021-06342_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information: i
D.T. Chalmers, Jr. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4146A ft. ft.
rt. rt.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a Gcable
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
N
2.Well Construction Permit#: ' "/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0 ft• 18 ft' 2 in. 0.010 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 18 rt. 28 It- 2 in' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) Oi Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
PIrrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 ft- 14.5 ft- bent. chips surface pour
X Monitoring 13 Recovery ft. ft.
Injection Well:
ft. ft. ,
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a lic9ble
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 14.5 & 28 ft- #2 Medium Sand surface pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) )Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock e, rain size,etc.
ft. ft.
4.Date Well(s)Completed:8/23/2021 Well ID#MW-04 ft. ft.
ft. ft.
5a.Well Location:
ED
OmniSource ft. ft. ' � I
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2830 US-421 , Wilmington, 28401 ft. ft.
Physical Address,City,and Zip ft. ft. .r nr ssi _ °Jijlt
New Hanover 21.REMARKSS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
34.27911 N -77.95544 W � ��� 9/8/2021
6.Is(are)the well(s)E)Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the vvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes 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#21 remarks section or on the hack 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: 28 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 t@t 200'and 2@100') construction to the following:
10.Static water level below top of casing: (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: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 Suably& 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rexised 2-22-20I6