GW1-2022-08719_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: F
T. Chalmers 14. 1ATER7OIVES
Well Contractor Name FROM TO DESCRIPTION
4146A ft. ft.
ft. ft. (
NC Well Contractor Certification Number N 5UiWCASOO f®r mldti coed five DR 11(NBR #fn ItcaLle
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 5 s• 1 in Sch.40 PVC
Ib.dNNER CASING DR THING 'Piithermal awedAyoil
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: l7.SCRERIY
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 5 ft 15 ft. 1 in. Slot 0.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) I8 GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 3 ft, Bentonite Pellets Surface Pour, 31b
:K Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
l9.SAIVAJGRA�EI.PACK`i!a icsldr
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 3 ft- 15 ft- Medium Sand Surface Pour 121b
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 30.DRTI.LING LUG 4ttachadditionalahceis ifecessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION color,hardness,soilt-ck type,grain size,etc.
4.Date Well(s)Completed:03/21/2022 Well ID#TMW-Z3-2
5a.Well Location:
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
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 laTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that th�w/l :.' s accordance
7.Is this a repair to an existing well: Yes or X No with 15A NCAC 02C.0100 or 15A NCACD2Q.Otj_ / s ME t,�J�and that a
co o this record has been provided to the well owner. ° "e
If this is a repair,fill out known well construction information and explain the nature of the PY r P �i p
repair under'21 remarks section or on the back o/this farm. i�AY 1U
23.Site diagram or additional well details MAY 2022
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also a4AftNJ;t01"P=d&ftseft
drilled: SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 15 (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdilferent(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,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
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
12.Well construction method: form within 30 days of completion of well
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 SunDly&Infection 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 Revised 2-22-2016
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