GW1-2022-08720_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers 74.WATE ZONES a
FROM TO DESCRIPTION
Well Contractor Name
ft.
4146A ft.
ft. ft. f
NC Well Contractor Certification Number
1S.13U7')81i C.1,S11�TG!'er rntr-cased.rve� iIR I�iI4ER a' lte�6lr �'� ',"....;.. '�'
FROM To DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists
2.3 ft• 5.5 ft. 1 in
Sch 40 PVC
Company Name 1 '1Nit1EIt GASllVbG OR 71T111NG- ermal aosed Ip"
. .::.......
2.Well Construction Permit#: 55.5ft-
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. in•
3.Well Use(check well use): ft. in•
Water Supply Well: L1TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 15.5 ft' 1 '"' Slot 0.010 SCh.40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18. Rd0I
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 3 ft, Bentonite,,Pellets Surface Pour, 31b
:x Monitoring ®Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
I9.Sr�Pf1NGRAVEL PACT{ f a' lle
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD\
Aquifer Test DStormwater Drainage 3 ft. 15.5 ft- Medium Sand Surface Pour 121b
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 28 1>RILLINC 1AG attach sddtteohalsliewit.neeeursa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft.FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.4.Date Well(s)Completed:03/21/2022 Well ID#TMW-Z4-1 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
Hanover 21.1tE1V1a1121
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
34/13/31.15 N 77/57/00.69 W
04/21/22
6.ls(are)the well(s)oPermanent or )( Temporary Signature of Certified Well Contractor Date a
By signing this form,I hereby certify that the well(s �s [ c rd nce
7.Is this a repair to an existing well: Yes or with!SA NCAC 01C.0l00 or 15A NCAC.01C.0200 e onstrucnon an ar s at 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. MAY
O ��
repair under"21 remarks section or on the back of this form.
23.Site diagram or additional well details:
72
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to prov� t �vsts�t well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach a a pa f)UgMry.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:de 15.5 (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 Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this'form within 30 days of completion of well
Geoprobe
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cennter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& 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. If
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016