GW1-2021-03291_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
George R. Bridget 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name ft. ft
2343A ft. It
NC Well Contractor Certification Number _15.OUTER CASING for multi-cased wells OR LINER if a licsble
FROM TO DIAMETER THICKNESS MATERIAL
Bridger Drilling Enterprises, Inc. 0 ft. 5 ft 2 sch40 pvc
Company Name 16.INNER CASING OR TUBING eothermal-closed-loon)
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) fit. ft !in.
3.Well Use(check well use): '17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 fit 10 ft. 2 in. .010 sch 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fit fit. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL; EMPLACEMENT METHOD&AMOUNT
❑Irri ation
Non-Water Supply Well: 0.3 ft- 2 ft Neat inplace
C�IMonitoring ❑Recovery ft. ft.
'
Injection Well: ft. tt
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 rt• 10❑Aquifer Test ❑Stormwater Drainage It sand inplace ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional''sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soNroek in size,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft. 0.2 ft I Asphalt Pavement
4.Date Well(s)Completed: May 10 2021 Well rD# MW-2 0.2 rt 5 ft Tari and dark gray sand/some silt
5 ft. 10 ft. :Gray fine to medium sand
5a.Well Location: tt. fa
Family Tire and Auto Service rt. ft
Facility/Owner Name Facility[D#(if applicable) fit. - ft
5429 Hwy 70, Morehead City tt. ft
I
Physical Address,City,and Zip 2t.REMARKS
Carteret
n prot;essl
County Parcel Identification No.(PIN) D V^111 $
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W �28242 !j May 21,2021
Si a of C ified Well Contractor i Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify 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
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction inrormation crud ex-plain the nature ofthe
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.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 10 (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@1001 construction to the following:
10.Static water level below top of casing: 5 (ft.) 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: 8 (in.) 24b.For Infection Wells ONLY: Ili addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: HSA 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
` F
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res y urces Revised August 2013
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