GW1-2022-08721_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
T. Chalmers ta.wAlrRlytvs
Well Contractor Name FROM TO DESCRIPTION
4146A
ft. ft.
NC Well Contractor Certification Number I ,f3U7$R CAS 1YG for mall rased wells U1ttiAVE11 t Ircahle
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 4 ft. 1 Sch.40 PVC
Company Name
Ib.1INNl�R CASIIIC*t1 7 tt$frTG: "thermal closed loo'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL _.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. & in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1r.SClS1Y
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 4 ft- 9 ft. 1 '"' Slot 0.010 SCh.40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL ft.
. Industrial/Commercial Residential Water Supply(shared)
f8.ORt)11� ,
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT x
Non-Water Supply Well: 0 ft. 1 ft, Bentonite'Pellets Surface Pour, 1 lb
:)Monitoring ORecovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge ElGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 1 ft. 9 ft- Medium Sand JSurface Pour 101b
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 2t1.DRYL L1AiG 1AC attach addttioiiailshsets if ni cessa
Geothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks)
FROM TO DESCRIPTION color,hardness,sail/rock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well ID#TMW-Z7-1 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 a1.,IaEtARI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: 1
34/13/31.15 N 77/57/00.69 W
04/21/22
6.Is(are)the well(s)oPermanent or laTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s) &gre constructed in accordance
7.Is this a repair to an existing well: []Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 ru +�n ff l(da .ter, at a
If this is a repair,.f ll out knot m well construction information and explain the nature of the copy of this record has been provided to the u ell oum =•�
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details: �tAgY n
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide ad l lorial l itj&t{ls or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach a 1 z es f necessary.
drilled: SUBMITTAL INSTRUCTIONS 00 Vrti'
9.Total well depth below land surface: 1 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@I00') construction to the f0110wing:
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
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
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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 one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to he 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