GW1-2021-07649_Well Construction - GW1_20211214

WELL CONSTRUCTION RECORD (GW-1) I For Internal Use Only:
1.Well Contractor Information:
D. T. Chalmers 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4146-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING forout ti cased wells'OR LINER tf a fieable
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft• 6.5 ft- 2 i" SCh. 40 PVC
Company Name
16.INNER CASING OR 1'UB1NG eothermal closed-loci"'
2.Well Construction Permit N: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construct ton pernuGs(i.e. f 4C.C'oump,.Gate, hariance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft• in.
17.
Water Supply Well: �1~ FROM SCREE TO DIAMETER Y SLOT SIZE THICKNESS MATERIAL
�rtcultural Municipal/Public 6.5 ft. 16.5 ft. 2 '"' Slot.010 Sch. 40 PVC
Geothermal(He�tin Cooling.Supply) Residential Water Supply(single)
'l8/ PP Y � Pp Y g ft. ft. in.
Industrial/Comrm,cial " Residential Water Supply(shared) Ig.GR017T
Irrigation Y'-� _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1.0 ft• 5.0 ft• Bentonite Pellets Surface Pour, 1181b
x Monitoring Recovery 0.0 ft• 1.0 ft- Concrete Surface Pour, 801b
Injection Well:
Aquifer Recharge Groundwater Remediation 19 SAND/GRAVEL PACK ifa icabte
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 5.0 ft• 16.5 ft• #2 Medium Sand Surface Pour
Experimental Technology Subsidence Control ft• ft•
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach zddi6odal sheets if necessa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under k21 Remark) ft. ft.
4.Date Well(s)Completed: 11/16/2021 well ID#N4GW24R
5a.Well Location: ft. ft.
MCAS Cherry Point N/A ft. ft. p
Facility/Owner Name Facility ID4(if applicable) ft. ft. 0�
Bldg. 133 Harrison St., Cherry Point, NC 28532 ft• ft• ,�,p
+vs r
Physical Address,City,and Zip ft. ft. )PN'� �ATIM
Craven County N/A 21.'REMARKS W!i
County Parcel Identification No.(PIN) RE ORIGINAL DRILLING LOG
WELL-
SE
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.89175750 N -076.89875400 W ���`� 11/24/2021
6.Is(are)the well(s) x, Permanent or Temporary Signature of Certified Well Contractor Date
By signing this/orm,l hereby cent&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JqNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the hack o/'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 1 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: 16.5 (ft)
P 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depilis ifdt//erent(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing:6.3 Division of Water Resources,Information Processing Unit,
/Jwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
H.S. Auger 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.field(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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016