GW1-2022-08716_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers 14:WATER7.ONES i3
Well Contractor Name FROM TO DESCRIPTION
4146A ft. &
ft. ft.
NC Well Contractor Certification Number IS.OU'I'ER CASING form 16496ed,ttiells OR LINER, A li�hlC �� ,,:„
CATLIN Engineers and Scientists FROM TO DIAMETER, THICKNESS MATERIAL
3.3 ft• 1.5 ft- 1 �. '" Sch.40 PVC
Company Name f§INNER CASING oR TUBING. eriHrermal closed too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1T SCItEIEN
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 1.5 ft• 11.5 ft- 1 '"'' Slot 0.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft ;"
Industrial/Commercial Residential Water Supply(shared)
1&GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 0.5 ft. Bentonite Pellets Surface Pour, 1 Ib
x: Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
I9.SAIVDIGRAVRL PACK if a is me
Aquifer Storage and Recovery
q g Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 0.5 ft- 11.5 ft. Medium Sand Surface Pour 101b
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer A DRILLING LOG attach adttitiorialishcets if aeCessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well iD#TMW-Z11-1 ft. ft.
5a.Well Location: ft. ft.
Riverman
Facility/Owner Name Facility ID#(if applicable) ft. ft.
720 Surry Street, Wilmington, NC 28405 ft. ft.
Physical Address,City,and Zip ft. ft.
Hanover z1.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong 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,I hereby certify that they° s st e t cordaoce
7.Is this a repair to an existing well: ®Yes or E)No with 15A NCAC 02C.0100 or JSA NCAC;02Cg 02� �r and that 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 well owner. (�
repair under'-'21 remarks section or on the back of this form. r�A!�/ i 2 Q 22
23.Site diagram or additional well'details:t
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additi nal well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also att00
�d� a
drilled: SUBMITTAL INSTRUCTIONS II
9.Total well below land surface:depth 11.5 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following: I ,
10.Static water level below top of casing:N/A (ft.) Division of Water ResourcesI ,Information Processing Unit,
I/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 lone 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