GW1-2022-06357_Well Construction - GW1_20220705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers 1a:WATER ZONES:
FROM To DESCRIPTIOK.... . .
Well Contractor 1\amc ft. ft, '
4146A
ft, fG
h1C Lt'cll Contractor CeniOcaiion Number 15.OUTER CASING for multi-cased evelts OR'LdNER If a disable
CATLIN Engineers and Scientists FROM T( DIAM£TEn T1"IT"RA 5 8tA'TERIAL
() ft. 2 n' 1 din. SCh,40 PVC
Cnnupany Name
I6.INNER CASING OR TUBING(leoth rtnal closed-loo
2.Wrcll Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List oil applicable well construction permits(4e,UIC,Connn:State,d ur•iance,etc.) ft• ft. in.
3."'ell Use(check well rise): ft. ft.
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE TOICKNESS MATERIAL
Agricultural iviunicipal/Public 2 a. 12 ft- 1 in. siot.mo Sch.40 PVC
Geothermal(Heatingcooling Supply) Rcsidential Water Supply(Single) ft. ft,
IndastriaFCommerciai •Residential Water Supply(shared) '' Ira.GROUT
Irr't atian
FROM TO MATERIAL. E<[PL.ACF.htENTAIFTD(.)D&AAtOtr%T '
Non-Water Supply Well: ft. ft. I
R Monitoring Recovery ft. ft. t
injection Well: ft. ft.
Aquifer Recharge Groundw'atcr Reinediation t
19.SANDIGRAYEL PACK if applicable)
.-Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormw.ater Drainage
Experimental Technology Subsidence Control
Geothem)al(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets If incessn )
FROM TO DESCRIPTION(color.hardness.soil••rod,h_'rse,it-i sin,sir.
Geothermal{FleatinufCctoling Return} Other(explain antler�'2I Remarks) ft. it.
4.Date Well(s)Completed:06/02/2022 Well lD4TMW-05 ft. ft.
5a.Well Location: ft, ft. a t k _L_s" V
Gecsyntec ft. ft.
Facihty�Osvncr teams Facility ID";(ifapplicable) ft. rr,
719 S. Third St. Wilmington NC 26401
t r r lr,�:.�
Physical Andras.City.and Zip fl, ft.
New Hanover 21."MARKS
County Parcel Identification No.(111N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latilong is sufficient) 22.Certification:
34.225833 It 77.944167 w 06/24/2022
6.Is(are)the weil(s) . Permanent or R 'temporary Sigratnrc orCcnified Well Contractor Date
Bt`signing this form,1 herchr•ceriUj-that the i ell(s!it-as(here)constructed in accordance
7.Is this a repair to an existing well [31`es or R)No unh 15A NCAC 02C.,0100 or 15.4 A'C.4C 472C.0200 Well t;onsirriction Standards and that a
lfthis it a repair.Jill our known u ell onstrw fion igforn.ofian and explain the nature of the copy gfthis record has been provided to the urll owner.
repoia under 1121 reurarls section or on the hn<^k of this form, 23.Site diagram or additional well details:
S.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 form within 30 days of completion of well
For nwhiph'ovens ldst all c.•cfrths ij"."!0rrew(example-3;i,200,and 2ui;100') construction to the following:
10.Static water level below top of casing:0'Q (ft.) Division of Water Resources,Information Processing Unit,
I rarer icrel is above casing.we 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.-2 (in.) 24b.For iniection Wells: In addition to sending the form to the address in 248
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 WATCR 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(cs) above, also submit one copy of this form within 30 days of
I3b.Disinfection hype: Amount: completion of well constriction to the county health department of the county
where constructed.
Fortn G11'-1 North Carolina Depanrnew of Environmental Quality-Division of Water Rcsourc;n. Revised 2-22-2016