GW1-2021-06959_Well Construction - GW1_20210505

1. vv ell l.Ulalractur 1111Ur111a11U11;
Michael Radford
Well Contractor Name
4267A
NC Well Contractor Certification Number
Bridger Drilling Enterprises, Inc.
Company Name
2. Well Construction Permit #:
1A}-1t � -ny�trt� 1 j•„1
r'1 n. •
1ttt.a;'t' q'0'il
2021
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
( Agricultural
Geothermal (Heating/Cooling Supply)
pIndustrial/Commercial
J Irrigation
Non -Water Supply Well:
xi Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
,J Aquifer Test
Experimental Technology
BGeothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 3/31/21
5a. Well Location:
Town of Surf City
Facility/Owner Name
173 Sarge Martin Road
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
IDRecovery
Groundwater Remediation
Salinity Barrier
DI Stormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# PW-1
Facility ID# (if applicable)
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 28 53.8623 N -77 32 57.8815
6. is(are) the well(s)IX Permanent or 0Temporary
7. is this a repair to an existing well: IjYes or x, No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 112/ remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 22
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 2 (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 8 (in.)
12. Well construction method: HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
-14:MATERZONES "' i41 .x r ,.
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
1
i x15. OUTER CASING:(for multl casei7 wells)'ORMINER (if ap
lieitili)VSKVAVVIV.
MATERIAL
FROM
TO
DIAMETER'
THICKNESS
0 ft.
7 ft.
4 'n•
SCH 40
PV
16 1NNER
CASING;OR TUBING:(ge"'othermillclo"s'ei1=1i'd`p")a
AMTO ,.,
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
47.SCREEN.,
A: a
' §fit x
, w r.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
7 ft.
22 ft.
4 in':
.010
SCH 40
PVC
ft.
ft.
in.
18:_GROUT
.•_
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft•
1 ft•
Neat
in place
ft.
ft.
ft.
ft.
19 SAND/GRAVEL
EACK{ifappliaible)
,
, ,
FROM
TO
MATERIAL
EMPLACEMENT METHOD
5 ft.
22 ft•
Sand ,
in place
ft.
ft.
24.1)RILLING' OG(attachreddiiionilsheets'f:iieees"siiy
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
16 ft•
Gray Fine to Medium Sand
16 ft'
22 ft'
Dark Gray Sandy Clay
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft. ft.
'21.-REMARKS'1,1-',,:'
22. Certification:
Signature of Certified Well Contractor
4/27/21
Date
By signing this form, 1 hereby certifit that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this f form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells. In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
completion of well construction to the county health department of the county
where constructed.