GW1-2022-08718_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers 14.W.ATERZONES
Well Contractor Name FROM TO DESCRIPTION
4146A
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING,for mob cased welts ORJ;WER" f s"
licalila :`s.
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
-1.5 ft- 13.5 ft. 1 '" Sch.40 PVC
Company Name 1t INNER CAS1WW QR TUVING #h'eir I dosa400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: IT SCREEN
EEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 3.5 ft. 13.5 ft- 1 in., Slot 0.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr. ft. in.
Industrial/Commercial Residential Water Supply(shared) lg GRUUT
_ Irrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 ft, Bentonite Pellets Surface Pour, 21b
x Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation t9 SAPl1)/GRAM LPACTC'fa 1de
Aquifer Storage and Recovery OSalinq Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 2 ft. 13.5 ft. Medium Sand Surface Pour 101b
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2t1.DWLLINGLUG atfaehaddifion>slsheetsif>xeeasa
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
ft. ft.
4.Date Well(s)Completed:03/21/2022 Well ID#TMW-Z3-1 ft. ft.
5a.Well Location: ft. ft.
Riverman ft. 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 z1.R�iHAR1cs
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 X/ /; ,.
04/21/22
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this.form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or [9No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WR
rds 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.iorm.
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 addilld;^v w soe 2 or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ��il0tidi8�fk391 PP��Urld
9.Total well depth below land surface: 13.5 ft
p ( ) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@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&Iniecti In 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 tolthe county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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