GW1-2021-05322_Well Construction - GW1_20211001

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells --n C
1.Well Contractor Information:
�+� 14.WATERZONES
George Bridger I
A I
f) _ FROM TO DESCRIP ION
Well Contractor Name —y� ft. it.
2393A pSa� ft. ft.
NC Well Contractor Certification Number tCf 3�,0 p Se . 15.OUTER CASING for mulfi-cased wells OR SS LINER ira livable
FROM TO DIAMETER LINER
MATERIAL
Bridger Drilling Enterprise, Inc. 0 ft. 5 ft• 2 '" sch40 I pvc
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit fr. in.
List all applicable well pernnit.r(i.e.County,Slate, Variance,hjection,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 f" 15 ft- 2 in. .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 2 rt. neat in place
Non-Water Supply well_•
@Monitoring ❑Recovery
Injection Well: rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
LA
❑Aquiter Storage and Recovery ❑Salinih�Barrier FROM TO MATERIAL EMP CEMENTMETHOD
3 rt• 15 ft• sand in place
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soillrocktype,grain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 1 ft. ! Asphalt and base coarse
1 ft. 3 ft. Tan sand
4.Date Well(s)Completed: 9�7�21 Well ID# MWS. . . .
3 rt. 8 tr. Gray clayey sand
Sa.well Location: 8 15 ft. Gray Sand
Quality Oils ft. ft.
Facility/Owner Name Facility IDk(ifapplicable)
rt. ft.
415 US 117, Burgaw 28425 H. ft.
Physical Address,City,and Zip
21.REMARKS
Pender
County Parcel Identification No.(PIN) It
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field:one lat/long is sufficient)
34 33 30 N 775510 , 9/14/21
Si ur Certified\yell Contracto Date
6.Is(are)the w'ell(s): @Permanent or ❑Temporary ,,. n,ing this form 1 herehv certify that the wells)was(mere)constructed in accordance
I5A tVCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ojthic record has been provided to the well owner.
Ijthi.s is a repair,jilt out known well construction information and explain the nature ojthe
repair under r,-21 remarks section or on the back ofihis 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 sate construction,via can
Nublun one fornt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
l ins unr/rip/e we/ls list a//depths ijdijferent(example-3 rr 200'and 2@100') construction to the following:
10.Static water level below top of casing: 1.5 (ft.) Division of Water Resources,Information Processing Unit,
ljwaier leve/is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For lniection Wells ONLY: !In.addition to sending the form to the address in
Direct Push 24a above, also submit a copy of this form'within 30 days of completion of well
Well ell construction method: construction to the following:
(i.e.auger,rotary-cable,direct push,etc.)
Division of Water Resources,Underground Injection.Control Program,
FOR NVATER SUPPLY WELLS ONLV: 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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