GW1-2022-08717_Well Construction - GW1_20220510

,r111��aa
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
T. Chalmers warlt:zats
Well Contractor Name FROM TO DESCRIPTION
4146A ft. ft.
ft. ft.
NC Well Contractor Certification Number
.()U7'ER GASITtG'foi•mitltrcased':ive#LS ORI�INER, fn hcAlil�: „�.;:
CATLIN Engineers and Scientists IS FROM TO DIAMETER THICR7VESS MATERIAL
Company Name _3 ft. 2 ft. 1 1° ,Sch 4(] PVC.
1fr.11t1NR CASifii Ult 1 U13119G thermal clot etl lua .:
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: 17 SCitEE11t
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 2 ft- 12 ft. 1 1° Slot O.o10 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) i8�1tC31T1
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft. Bentonite Pellets Surface Pour, 11b
: Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
I9:SANDJGItAYf I PACit if a hje
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 1 ft 12 ft Medium Sand Surface Pour 101b
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) E3Tracer 3t1.IfRILL1NG 1AG attachadiiHoa>dlsheets ifnecessa
FROM TO DESCRIPTION color,hardness,soiUrock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:03/21/2022 Well ID#TMW-Z1-2 ft. ft.
5a.Well Location: fa ft.
Riverman ft. I ft.
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
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: !�
34/13/31.15 N 77/57/00.69 W . , ,�
� '� «,. 04/21/22
6.Is(are)the well(s) Permanent or E)Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)wa.s.[were)constructed in accordance
)
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeLp
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. !N, 1O 8.,/y
repair under Ul remarks section or on the back of this form.
23.Site diagram or additional well details: p�nv �� ^�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page io provide additi0 Ali Iwel i d(t �Zr.11
construction,only1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
MIIOtaeatit an ProceG ang Urlio
drilled: SUBMITTAL INSTRUCTIONS Db COOG
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 wells list all depths ifdierent(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,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&Iniectio'n Wells: In addition to sending the form to
the address(es) above, also submit+one copy of this form within 30 days of
i
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. f{
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016
i
k