GW1-2022-09703_Well Construction - GW1_20220510

. Print Form ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j o
1.Well Contractor Information:
T. Chalmers I4.WALTERZONES
Well Contractor Name FROM TO DESCRIPTION
4146A
ft. ft. 6
NC Well Contractor Certification Number 15.()I37 6R CASING ter meltied`aeUs OR LINER f n luyrble ,,,
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 2 in. Sch.40 PVC
Company Name 3b,INl9ER CpsIN G tNt T[TBING thermal dosed-loe r:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: tfi.SCREEbt
FROM TO DIAMETER SLOT SIZE THICKNE I MATERIAL
Agricultural [3Municipal/Public 2 ft- 12 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) I8 GR01JT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft, Bentonite Pellets Surface Pour, 1 lb
:)Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
l9.SAA10/6RA1' LPACK fa icalle
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 1 ft- 12 ft- Medium Sand Surface Pour 101b
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 29.DRILLING LUG attach additional Sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well iD#TMW—Z8-1 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. h.
Physical Address,City,and Zip ft. ft.
Hanover 21•Ia Ei13ARlZS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
34/13/31.15 N 77/57/00.69 W `�u�f�," -- 04/21/22
6.Is(are)the well(s)oPermanent or XTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells) ere)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 s andards 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 form. ` r
23.Site diagram or additional well details: an vv --�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide adliliKkal 1co.1i t►s or well
construction details. You may also attach al pages if nece�
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells �iai. _ P
drilled: SUBMITTAL INSTRUCTIONS D11'0'j0G?'1r'19 Urkh
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 if dierent(example-3@200'and 2@100') construction to the following:
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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
IL Borehole diameter: (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�ohe 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-1 North Carolina Department of Environmental Quality-Division of Water Resources k Revised 2-22-2016
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