GW1-2022-09704_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ; p
1.Well Contractor Information: I
T. Chalmers 14.WATER7oNE5
Well Contractor Name FROM TO DESCRIPTION
4146A ft. ft.
ft. ft.
NC Well Contractor Certification Number IS.atiTER CAS11iG f®I witi eased wells dRLINER Ifs` hta6le "'
CATLIN Engineers and Scientists FROM TOI DIAMETER h THICKNESS MATERIAL
0 ft. 9.5 ft. 1 in Sch 40 PVC
Company Name
lb.INNER CASING,OTt'TUDINQ ealirermal closed 100 .
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): It. ft. in.
Water Supply Well: 1T SCTthEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 9.5 ft. 19.5 ft- 1 in. Slot 0.010 Sch.40 JPvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18 CRUVT
i Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 7 ft, Bentonite'Pellets Surface Pour, 71b
X Monitoring ORecovery ft. ft.
Injection Well:
ft. ft. i
Aquifer Recharge Groundwater Remediation
l9:SAIVIl1G1tA1'EL PACT{if a lite
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 7 ft 19.5 ft Medium Sand ISurface Pour 151b
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LUG attach additional sh6ets if.rtecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rockrain size,etc.
ft. ft.
4.Date Well(s)Completed:03/22/2022 Well m#TMW-Z9-2 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 21.REMARKS "
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:
34/13/31.15 N 77/57/00.69 W '� ' '=- 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 ,el s t ante
7.Is this a repair to an existing well: ®Yes or E)No wish 15A NCAC 02C.0100 or 15A NCAC 02C.02 1 e r tion J r s n� hat a
1f 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
repair under#21 remarks section or on the hack of this form. M AY 1
23.Site diagram or additional well details: 4 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach {dub8e UrA
drilled: SUBMITTAL INSTRUCTIONS MURM
5
9.Total well depth below land surface: 19. (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:
10.Static water level below to of casing:N/A ft.
p g: ( ) 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& Injection Wells: In addition to sending the form to
the address(es) above, also submit ion"c copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to i e'county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
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