GW1-2021-06888_Well Construction - GW1_20210505

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ge0 , R. Bridge 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2393A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multicased wells OR LINER if a licable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER .THICKNESS MATERIAL.
ft. 2 ft. 1 2 in. sch 40 PVC
Company Name '
16.INNER CASING OR TUBING eotherma]closed-loop)
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): ft' ft' in.
I17.SCREEN
N
ater Supply Well: .
FROM TO DIAMETER SLAT SIZE THICKNESS MAT IERIAL
Agricultural 13Municipal/Public 2 ft. 7 it. 2 in., .010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in
Industrial/Commercial 18.Residential Water Supply(shared) GROUT
MATERIALl Irrigation FROM TO MATERIAL
EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: 0 ft. 1 ft- neat in place
Monitoring Recovery ft ftjection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL" EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 1.5 ft. 7 ft. sand ! in place
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILL LOG attach additional sheets'if necessary)
'
Geothermal Heatin Conlin Return FROM TO DESCRIPTION color,hardness soil/rock in size,eta
Other(explain under#21 Remarks 0 fL 7 ft. Gray Fine to Medium Sand
4.Date Well(s)Completed: 3/31'/210 Well ID# MW2 ft. fL
5a.Well Location: % ft.
Holiday Trav-L-Park fL ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
9102 Coast Guard Road ft. ftM , ' �m
Physical Address,City,and Zip
Carteret 21 REMARKS
County Parcel Identification No.(PIN)
�Y di?il'i�`"'p�:nd!� `�,.�.•''{`Oil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I
34 39 37 N -77 03 35 W
z I
6.Is(are)the well(s) Xi Permanent or Temporary sign Ce ed e n ctor Date
silting this form,I hereby certify that the,well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EJNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards 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.
23.Site diagram or additional well details:
You may use the back of this page!to provide additional well site details or well
8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same �
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS 4
9.Total well depth below land surface: 7 (ft.) 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 following:
10.Static water level below top of casing: 2 (N Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
m.11.Borehole diameter: 4 I
( ) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Direct Push 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&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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
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