413440_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
For Internal Use ONLY:
A1'311
George R. Bridger
Well Contractor Name
2393A
NC Well Contractor Certification Number
Bridger Drilling Ent., inc.,dba Carolina Drilling
Company Name
2, Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. WelI Use (check well use):
Water SupplyWell:
EiAgricultural
DGeothermal (Heating/Cooling Supply)
Dl Lndustrial/C mmercial
Obligation
DMucipal/Publ.ic
DResidential Water Supply (single)
[°Residential. Water Supply (shared)
Non -Water Supply Weil:
l2lMonitoring
CDRecovery
Injection Well:
(.Aquifer Recharge
°Aquifer Storage and Recovery
° Aquifer Test
CDExperimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Realm)
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
Subs idence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Weil() Completed: April 19, 2013
5. Well Location:
Town of Rose Hill
Facility/Owner Name
Facility ID# (if applicable)
Corner of Walnut Street and Church Street, Rose Hill, 28458
Physical Address, City, and Zip
Duplin
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
349' 32.06" N 78 01' 15.46"
6, is (are) the well(s): ta Permanent or D Temporary
7, Is this a repair to an existing well: °Yes or IDNo
1?f this is a repair, fill out known well construction information and explriin the nature of the
repair under #21 remarks section or on the back of this form,
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY Ivith the same construction, you can
submit one form.
1
9. Total well depth below land surface:
For multiple wells list all depths if different [example- 3@200' and 2@:1OO')
13
10, Static water level below top of casing: 5.83
if water level is above casing, use "4- „
11. Borehole diameter: 10 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
13. FOR. WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft,
ft
ft.
ft.
15. OUTER CASING (for multi -eased wells) OR LINER(if apnyeable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
3 ft
2 in.
sch 40
pvc
16. INNER
CASING OR TUBING
(geothermal riosed-loop)
FROM
TO
DIAMETER 1 THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
` THICKNESS
MATERIAL
3 ft-
13 ft-
2 in.
010
sch40
pvc
ft.
ft.
in.
18, GROUT
........
:.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOINNT
0 ft.
.1 ft*
_
neat
in -place
ft.
ft.
ft.
ft.
19. SAND/GRAL PACK
(if appli le):........:: :::.::.:.... .
FROM
TO
MATERIAL
EMPLACEMENT METHOD
2 ft
13 ft
sand
trernie
ft.
- ft.
.
20. DRJLEING
LOG (attach additional sheets if necessa :.. .
FROM
TO
DESCRIPTION (calor, hardness, se crock type, grain lei ete.)
0 ft.
ft.
Tan and Gray sand
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
„ , �}, IZf c
ft.
ft
v •
ft,
fit.
VAT L e it .1u1 a, " r • NI
fir, '4,
44Z
kd
rf��T
22. Certification*
e of Certified Well Contract
April 30, 2013
Date
fining this f ornt l hereby certi. f , that the well(s) was (were) constructed in accordance
wzili 15A NCAC 02C .0100 or 15A NCAC 02C .O200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
Yon may use the back of this page to provide additional well site details or well
constriction details. You may also attach additional pages if necessary,
24. Submittal Instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following;
Division of Water Quality, information Processing Unit,
1617 Maid Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of complexion of well
construction to the following:
Division of Water Quality, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constricted.
Form GW-1
North Carolina Department of Ectviromnent and Natural Resources — Division of Water Quality Revised Jan. 2013