GW1-2021-06956_Well Construction - GW1_20210505

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1. W C11 l,Ullll'al'lUr 1111U1'111a11U11: I I I
Michael Radford ^I 14,xWATER°ZONES u, °.K, -rk_ _ x_
Well Contractor Name 4"' '. 1,) 1,,'_.>' FROM TO DESCRIPTION
4267A
21 rt. ft.
NC Well Contractor Certification Number "'V
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15."OUTER CASING ;mulh casedwblls`:OR;L`INER`fa"'"lieatile a77
Bridges Drilling Enterprises, Inc. �.,.,��r„r; )1)'is)) FROM TO DIAMETER THICKNESS MATERIAL
Company Name m+lv 'U,•yrI "�,';: 1 0 ft. ft. 2 in.
sch40 PVC
16tINtVER;CASING;URxTUBING, "eothertnal;:clbsed-mooA a qg „�Ir
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits 0.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 47 SCREEN.
FROM TO I DIAMETER SLOT SIZE I THICKNESS I MATERIAL•"
C Agricultural nMunicipal/Public ft. rt. in..
� 22 2 .010 sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18:,GROUT ;a '
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft. Neat i in place
xj Monitoring J Recovery ft. ft.
Injection Well:
Aquifer R.ech?rge ft. ft.
GrOundv✓at2;Remediation
Aquifer Storage and Recovery Salini Barrier Al9 SAND/GRAVEUPAGK(if,a"'"licable`t s'
p+� ty FFROM TO MATERIAL EMPLACEMENT METHOD
_'Aquifer Test []Stormwater Drainage ft• 22 ft• Sand in place
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Oj Tracer RILLING L"OG,attach additional sheets if necessaGeothermal(Heating/Cooling Return) _!Other(explain under#21 Remarks) TO DESCRIPTION cams hardness,soiVrock type,gmin sae,etc.
0 ft. ft. Gray Fine to Medium San
4.Date Well Completed: 3/31/21 Well ID# OW-3 - tt ft. 24 ft.
Dark Gray Sandy Clay,
5a.Well Location:
Town.,6f Surftity. _:e
Facility/Owner Name _„_,•FacilityJDk-(ifapplicable) ft. ft., .
173 Sarge Martin Road rt. rL
Physical Address,City,and Zip
OIISIOW -_.. '1LREMARKS°. •';
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 28 53.9330 N -77 32 57.8815 w
4?11� 4/27/21
C Is(are)the well(s)�IX Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, t hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3ves or 'k®No with l5A NCAC 02C.0100 or lSA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fi/l out known well construction it jirtnation and explain the nature of the copy of thts record has been provided to the well owner.
repair under p21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8:For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page ito,provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22 (ft•) 24a. For All Wells: Submit this�f0im within 30 days of completion of well
Fnr multiple wells list all depths ifd!ferent(example-3@20p'and 2 rt100') COnSt[UCtIOn t0 the f0110W1ng:
10.Static water level below tom of casing:
2
1 g (ft.) Division of Water Resources,Information Processing Unit,
If oaten level is snore casing,nine 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 _(in.)_. 24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well coustruction'tuethoil. HSA above, also submit one copy of this form within 30 days.of completion of well
('. .'au auger,rot ,cable;direct ) -—" construction t0 time following:
1 e g .Iry push,etc.
...
— Division of Waterater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service nter;Raleigh,NC 27699-1636
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�the county health department of the county
where constructed.
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