GW1-2022-06356_Well Construction - GW1_20220705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
T. Chalmers 14.WATER ZONES:
FROM TO DESCRIPTION
Well Contractor Name
4146A
NC Well Contractor Certification Number IS.:OUTER CASING for wells OR 'E 5 —d we 0 N I ap"
FROM To I MATERIAL
CATLIN Engineers and Scientists multi
RNLI—MMU -1 lle)�
Company Name 0 ft. 2 IL I I "- I Sch.40 P.VC
16.INNER CASING OR' BING(geothermal closed-loop)
2.Well Construction Permit 9: FROM Tos DIAMETER THICKNESS 51ATEFLIAL
List oll oppficable wll constrorliorl Permits A e,1.11C,Count;.Slow.Variance.etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
W .ater Supply W 17 SCREEN
ell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural [)Municipal/Public 2 It. 12 u. 1 in. I Slot.010 SCh.4=PVC
:J(;e,,!Iier;nal(HeatirigfCoofing Supply) 0,Residential Water Supply(single) ft. ft.
:31rdustrial?Coninicrcial 0-Residential Water Supply(shared) 18.GROUT.
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supph,Well-, ft. ft.
:X)Monitoring DRecovery
Injection Well:
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK fire licable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO ASATERiAL ENIPLACENIENTMETHOD
Aquifer Test [3Storniwatcr Drainage ft. ft.
Experimental Technology [3,Subsidence Control ft, ft,
Geothermal(Closed Loop) Tracer :X DRILLING LOG(atlach additional sheets If necessarv)
ft.
Geothennal(Heat ing;Cool ing Return) []Other(explainunder#21 Remarks) FROM ft. TO DESCRIPTION(color.lmrdmss.soit1r.ek tpc.i,,An sue,etc.)
4.Date Well(s)Completed-06/02/2022 Well]D#TMW-03 ff.
Sa.Well Location., ft. ft. q--"t
Geosyn ft. ft.tec I L_'_4 V k--
racilfty.'OwncrNainc Faciiii),lD#(if applicable) ft, ft. - 2022
71'9 S. Third St., Wilmington, NC, 28401 4 ----
Physical Address.City.and Zil, fC. ft. Ufl"
New Hanover REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
34.225833 N 77.944167 W 06124/2022
..........
6.Is(are)the wells) Permanent or [nTemporary Signature of Date
kv signing durr form,I herebil rvri?f),that the urd(s�)wan Nvre)vonstructed in accordonce
7.Is this a repair to an existing well: Dyes or ®No with 15AXCAC 02C,010 or 15.4AC4C 01CX200 Well Consinietion Standards and that a
If this is a repair,fill 0111 known u-cil construction information and explain the nature oJ'file CoAr oftlas record has been provided to the twfl of mil
repair under 921 remarks'section or on the back(?f thisfiorin, 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-I 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 form within 30 days of completion of well
For multiple wells list al/depths if differeat(exaniple-3,,ii2(10'and 2,14,100') construction to the following:
10.Static water level below lop of casing:8.0 (ft.) Division of Water Resources,Information Processing Unit,
11 isvier level is above casing.arse­+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2 (in.) 24b.For Injection Wells: In addition to sending the forrii to the address in 24a
12.Well construction method: DPT above,also submit one copy of this form within 30 days of completion of well
(i.e
.auger,rotary.cable.direct push.etc.) construction to the following:.
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 Wills: In addition to sending the form to
the address(es) above, also subinil one copy of this form within 30 days of
13b.Disinfection type: Amount; compleion of well construction to the county health department of the county
where constructed.
Form GW.I North Carolina Deparimeni of Envirornmotal Quality-Division of Water R c5oum* Revised 2-22-2016