GW1-2021-06344_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
D.T. Chalmers, Jr. 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4146A ft. ft.
ft. ft.
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. in.
Company Name
/� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: N/- - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc) 0 ft 2 IL 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 2 ft. 12 It. 2 in' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.7 ft. 1.5 ft. bent. chips surface pour
X Monitoring ORecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 1.5 ft- 12 fL #2 Medium Sand surface pour
_ Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _j Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck e, rein size,etc.
ft. ft
4.Date Well(s)Completed:8/23/2021 Well ID#MW-06 ft. ft
5a.Well Location: R. ft. !.�
OmniSource ft. ft. S �~
Facility/Owner Name Facility ID#(if applicable) ft ft.
2830 US-421 , Wilmington, 28401 ft. ft.
Physical Address,City,and Zip ft. ft. !avu I i,;jti{7i
New Hanover 21.REMARKS
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:
34.27664 N -77.95374 W D � 9/8/2021
6.Is(are)the well(s)�IX Permanent 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: E Yes or ONo with ISA NCAC 02C.0100 or ISA 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 wel/owner.
repair under#21 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: 12 (ft.) 24a. For All Wells: Submit this I'form within 30 days of completion of well
For multiple wells list all depths fit dierent(example-3@200'and 2@I00') 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 Supply& Injection'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