GW1-2022-08715_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers 14.WATER ZONES`—
Well Contractor Name FROM I TO DESCRIPTION
ft. ft.
4146A NC Well Contractor Certification Number ft. ft.
15;t3111ER CAS1iTG for maltied;welts 011 LINBR f i Iteable
CATLIN Engineers and Scientists FROM TO WAMETEW THICR7VESS MATERIAL
3 ft. ft. j
Company Name 2 1 Sch.40 I PVC
1 ANNER CAS MG OR Tl7B1NG "thermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc) ft. ft. in,
3.Well Use(check well use): tt. k, in.
Water Supply Well: tT SCR11 N
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �MunicipaUPublic 2 ft12 ft- 1 1D- Slot 0.010 Sch.40 JPVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.'
Industrial/Commercial Residential Water Supply(shared) 48 GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft, Bentonite Pellets Surface Pour, 1 Ib
x Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
1'J.SANAJGRAV�LpACiC fa 1de
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test OStormwater Drainage 1 ft- 12 ft- Medium Sand Surface Pour 101b
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 30,DRILLING TAG attach additionolsheets ifli6 P sa
Geothermal(Heat ing/Cool ing Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilimck type,gmin size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well ID#TMW-Z 13-1 tt. ft.
Sa.Well Location: ft. ft.
Riverman ft. ft.
Facility/Owner Name Facility ID#(if applicable) L )F 1�
720 Surry Street, Wilmington, NC 28405 ft. ft. MAY
Physical Address,City,and Zip ft. ft.
Hanover zt•REll4ARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: /
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 wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 01C.0100 or 15A NCAC102C.0200 Well Construction Standards and that a
1f 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 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 site details or well
construction,only I 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: 12 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we//s list all depths ifdifferem(example-3@200'and 1@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,duet[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 SunDly& Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources k Revised 2-22-2016
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