GW1-2022-09229_Well Construction - GW1_20221003

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
D.T. Chalmers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4146-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi cased'wells OR LINER if a"lic3b►e's'
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop) 5
2.Well Construction Permit#: NA FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable well construction permits(i.e.(/IC;Counhc State, Variance,etc) 0 ft' 1.5 ft' 1 1°' SCH 40 PVC
3.Well Use(check well use): fL I ft, in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 1.5 ft- 11.5 ft• 1 an.j 0.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.L
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
(nMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -
19.SAND/GRAVEL PACK if s"licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 0 ft- 11.5 ft Native Backfill
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain sin,etc.
ft. ft. No Lithblogy provided
4.Date Well(s)Completed: 8/31/2022 Well ID# TMW-02 ft. ft.
ft. ft. Y
5a.Well Location:
FormerStevcoknit Fabrics Company NA ft ft
Facility/Owner Name Facility ID#(if applicable) fL ft 0 Ij T 6�
615 Old Wilmington Rd., Wallace 28466 ft. ft.
Physical Address,City,and Zip ft. ft
Pender NA 21.REMARKS
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: f
34.731518 N -77.986898 W 7 /�
9/28/2022
6.Is(are)the well(s): []Permanent or C1Temporary Signature ofCerrified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (!]No 15A NCAC 02C.0100 or 15A NCAC 02C.0200(Veil Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11.5 (ft.)
For multiple wells list all depths if d�erent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
NM 249. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1twater level is above casing,use"+" I
11.Borehole diameter: 2.5 (in,) 24b. For Injection Wells: Copy Ito DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Direct Push
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount:
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018