GW1-2021-03290_Well Construction - GW1_20210603

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contraclor Information:
George R. Bridger 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name ft. ft
2343A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mahitased wells OR LINER it applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Bridger Drilling Enterprises, Inc. 0 «. I5 ft 2 i SCh40 pvc
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 IL 10 ft. 2 in. .010 sch 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0.3 ft. 2 It. Neat inplace
Non-Water Supply Well: ft. ft.
ZMonitoring ❑Recovery
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK ifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 ft. 10 ft sand inplacetL �
❑Experimental Technology ❑Subsidence Control
20.DRELLiNG LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION cotor,hardness,sowr«k n size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft 0.2 ft Grass and Topsoil
4.Date Well(s)Completed: Well ID#
May 10,2021 MW_3 0.2 ft. 5 ft. Tan and dark gray sand/some silt
5 ft. 10 ft. Gray fine to medium sand
5a.Well Location: tt. fL
Family Tire and Auto Service
or
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
5429 Hwy 70, Morehead City JUN
ft. fL
Physical Address,City,and Zip 21 REMARKC
Carteret
,31ton Prose
County Parcel Identification No.(PIN) 11'
011
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tattlong is sufficient) 22.Certification:
N W 447� /le- Szz�ul May 21,2021
Si6datureofCcritifiedWell Contractor j Date
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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 IZJNo copy of this record has been provided to the well owner.
If this is a repair,fill out k.,own well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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 ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In 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
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
€purees Revised August 2013
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