GW1-2021-04692_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: +ti'
�-'r P
George Bridger , , L4:S11TERZOCVES
y-•„M- �"'� FROM TO DESCRI It PTION
Well Contractor Name � � nogg rt. 1't.
2393A
r Z.j;�:! �131t
NC Well Contractor Certification Number �l v. 7 15.O1iTER'CASING(116ir nulh easdi9>rells ORZ IAIER•if,a' licable
FROM TO DIAMETER THICKNESS MATERIAL
Bridger Drilling Enterpri6bs, 0 ft. 19 ft. 2 SCh40 I pvc
Company Name 16.3NNER CAS11yG ORrTUB1NG:`eothermalelosea lo ) x,
FROM TO DIAMETER THICKNESS a MATERIAL.
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County.State, Variance.Injection,etc.) it. ft. in.
3.Well Use(check well use):
17:SCREEN,"
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 9 ft. 24 ft 2 t° .010 1 Sch40 PVC
❑Geothermlal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18J ROUT To MATERIAL EMPLacEMENr n1ETHOD&AMOU
NT
❑Irri ation 0 rt. 5 rt. Cement in place
Non-Water Supply Well:
R iVionitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ':19.tSAND/GRAVEL`�PACK`ifa "licable
FROM TO MATERIALEMPLACE\1ENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 ft. 9 fL ISand In place
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 9 ft• 24 rt Sand Prepack
r30.`VRJL-LA'Gs13(SG aftactiaddtiiol`tal6heetsif-neces
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 rt. Brown Loamy Sand
5/3/21 131 5 rt. 15 rc• Gray Brown Silty Clay
4.Date Well(s)Completed: Well ID#
15 rt• 24 rt• Gray Gravely Sand
5a.Well Location:
Watson Electrical
Facility/Owner Name Facility ID#(if applicable) rt. ft.
2010 North Raleigh Boulevard, Raleigh, 27604
Physical Address,City,and Zi
Y Y P 21.REMARKS i.,'. �,�:,,,;ce`,s�,}d�"✓-� orb ;�, �c�: x;.
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient)
35.807662 N -78.602680 W _
Sign r Cert'r Well C r to
6.is'(are)fne weil(s):UNerman'ent or _,F etiiporary
v Wing this form./herebn cent fig al the wel!(s)was(were)constructed in accordance
th 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 ONo copy gf'lhis record has been provided to the well owner.
It"this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back oJ'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 ifnecessary.
For multiple injection or non-ivater supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24 (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
For multiple wells list all depths if different(example-3 cu 200'and 2G100) construction to the following:
10.Static water level below top of casing: 15 Division of Water Resources,Information Processing Unit,
1Jlvater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection 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
12.Well construction method: 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
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&Igiection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the coulity health department of the county where
constructed.
V
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i
I '