GW1-2022-06354_Well Construction - GW1_20220705

i
1
Pfint I,Orm
WELL CONSTRUCTION RECORD 6GW-1) For internal Use Only:
I.Well Contractor Information:
T. Chalmers 14.WATERZONES
FROM To D DESCRIPTIONWell Contractor Name
4146A
ft, ft.
NC Well Contractor Certification Number IS:OUTER CASING for i®rilfl eased'w'eas OR 1 INEIt'If a Itco0le
CATLIN Engineers and Scientists FRont o w S12-1 ER rxlcxrEss ntATERIA
a ft. 2 rt. 1 in. Sch.4a 1 PVC
Company Name
16.INNER CASING OR TUBING eotherroal closed400
2.Well Construction Permit M. FROM TO DIAMETER� THICKNESS MATERIAL
List fill applicable st-ell construction pernFits(i.v.LFIC,CPnnA-,State,S 1111ance,e1c.) ft. ft. in.
3,Well Use(check well use): ft. ft. in. I
Water Supply Well. FROM
SCREEN
FROM 'to E DIASTLTER SLOTSIZE TIIICKn ESS MATERIAL
Agricultural Municipal/Public 2 ft. 12 ft. 1 In. Slot.010 SCh.40 PVC
Geothermal(I lcatingiCoohng Supply) Eli-Residential 'dater Supply(single) ft. I ft.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation fRoit TO MATCRtAL F.ITPLACE,%tEKTmr.THon&AMOUNT
Non-Water Supply Well: ft. ft,
Monitoring Recovery ft. ft.
Injection Well:
ft, ft, I
Aquifer Recharge Groundwater Remediation I
19.SANDIGRAVELPACK iffapplicable)
Aquifer Storage and Recovery Salinity Barrier .FROM TO MATERIAL EvIPLACENIVNT 11ETHOD
Aquifer Test Stormwater Drainage ft. ft.
Experiimemal Technology Subsidence Control ft, fe,
Geothermal(Closed Loop) Tracer 20,DRII.IJNG LOG attach addidanst sheets ff neema
Geothermal(Heating,Cooling Return) Other(explain under#?1 Remarks) FRoat TO DESCRIPTION(Col-,hardnass,snl3lrncl t� c cnln sac ctr.4
ft. A. �
4.Date Well(s)Completed:06/02/2022 Wel!ID#TfV W-01 ft.
it.
Sa.Well Location: I
Geosyntee ft. fi. JUL 0 a 2022
Facilitlr'Owner Name Facility ID#(if applicable) ft. ft, ryr -
71 S. Third St., Wilmington, NC, 28401 ft. ft. "eet:n, o
PhBAddress.I t
Physical Address.City.and Zip it, ft.
New f)4��r '21.R£N1ARK9
im
County parcel Identification too.(PIN)
51D.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n
(if well field,one laillong is sufficient) 22.Certification: !!
34.225333 N 77.944167 W 06/24/2022
6.Is(are)the wells) Permahent or OTemporary Signature of ccnified Well Contractor Date
Rr sipping this,fertn,1 Itereln,s.'mt)fr that the rccllfs)Fras(werv)4.onsmi.oed in acr-ordunce
7,Is this a repair to an existing well; Elves or k No Fri+lt 13 t 1tC tC'li?C',.131f10 ttr I tri;\'C IC 02E',:4211(t lttefl Cansnatt7ion Srautdards and that a
1filds is a repair,fill out k timoi it-oil vonsnTi lion htfornwtion and explain tho nature a the copy of this record fins liven prm it$zi to the etl ll nes'ner.
repair wtrler d21 re•murktr section or on the hack of ibis Earn;. t
23,Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hailing the same You may use the back of this page to provide additional well site details or U'ell
construction,only I GW-1 is needed. Indicate-TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUIIMIT7'Al.INSTRUCTIONS
9.Total well depth below land surface- 12 {ft.) 24a. For Ali Wells- Submit this form within 30 days of completion of .vell
For inaltiple irelh,Ast all depths f'differeat ferawple-Z,2illy artd?((100')
construction in the faDlhumting: i
10.Static water level below top of casing: '� (ft.} Division of`rater Resources,Onformation Processing Unit,
!f tvater level is ahave easing.ow"M' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2 {itt.) 24b.For Injection Wells: In addition'to sending the form to the address in 24a
above,also submit one copy of tli;s form within 30 days of completion of well
12.Well construction method: ®PT(i.e.auget,rotary,cable,direct Push,ctc.I construction to the following: '
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set-vice 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(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.
I
Form OW-1 North Camiina%Dcparimem of Environmental Quality-Division of Water Resources Revised 2-22-2016