GW1-2022-09705_Well Construction - GW1_20220510

Print Form,,, ,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j p F e-
1.Well Contractor Information: i
T. Chalmers 14.WATIKWZONE9
Well Contractor Name FROM TO DESCRIPTIONft. ft.
4146A I
ft. ft.
NC Well Contractor Certification Number 1S,aU1ER`CASIIYG fer muff-e�edhwelti ORliiNER„t'ti Tsble s
CATLIN Engineers and Scientists FROM TO DIAMETER; TRICKINESS MATERIAL
Company Name 3 ft. 12 ft, 1 ' in Sch 40 PVC
16.INNLIL CASII+tG t)rt TCI1t1NG thermal dosed!oo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: IT SCl#EBN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 2 ft. 7 ft. 1 rn•' Slot 0.010 Sch.40 JPvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft in•
Industrial/Commercial Residential Water Supply(shared) IS GR01
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft. Bentonite'Pellets Surface Pour, 1 Ib
x:Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation }+�•SANDIGRAVEU FACK'af a licaiite
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 1 ft. 7 ft- Medium Sand Surface Pour 7b
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING 1:OG attach additiansl slicets ifcessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well ID#TMW—Z10-2 ft. ft.
5a.Well Location: ft. ft.
Riverman
Facility/Owner Name Facility ID#(if applicable)
720 Surry Street, Wilmington, NC 28405 ft. ft.
Physical Address,City,and Zip ft. ft.
Hanover 21,I2EiNA121r5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ;1
34/13/31.15 N 77/57/00.69 W
04/21/22
6.Is(are)the well(s)oPermanent or XTemporary Signature of Certified Well Contractor Date
By.signing this form,1 hereby certify that the well( tg+�' a ed dance
7.Is this a repair to an existing well: []Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.020 !!�v oo tXX d'at 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 we//owner. AI p�+,l'
repair under Ul remarks section or on the back of this form. MAY I /► 72
23.Site diagram or additional well details: Q 10
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pr vi a additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also; UM
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:N/A (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: 1 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe 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& Infection Wells: In addition to sending the form to
the address(es) above, also submit done 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. I{
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources R Revised 2-22-2016
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