GW1-2022-01783_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
George R. Bridgeer 14.WATER ZONES
Well Contractor Name ����'`\y`C,/r� FROM TO DESCRIPTION
ft. ft.
2393A �•• ft. ft.
NC Well Contractor Certification Number pp 4 2e2�
�"tD 1 15.OUTER CASING for multi-cased wells OR LINER if a livable
Bridger Drilling Enterprises, Inc. FROM To DIAMETER TAICIINESS MATERIAL
0.5 ft. 9 ft. 2 rn• sch 40 pvc
Company Name , i16.INNER CASING OR TUBING eother of closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): fa ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural Oj Municipal/Public 9 tt. 19 ft. 2 in.
010 sch ao pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. ;n
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.75 ft- 6 ft- neat inplace,<0.1 cyd
x Monitoring _ Recovery ft. ft.
Injection Well:
ft. ft.3__I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test DStormwater Drainage 7 ft. 19 ft sand Prepack and tremie
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
NGeothermal
(Heating/Cooling Return J Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soilfrock tyM gmin sbA etc
0 ft. 19 ft* Tan Fine to Medium sand,
4.Date Well(s)Completed: 1/12/22 Well ID#MW 9 ft. ft.
5a.Well Location: ft. ft.
Naman Judson, LLC ft. ft•
ft ft.
Facility/Owner Name Facility ID#(if applicable) '
520 Judson Church Road, Fayetteville
Physical Address,City,and Zip ft. ft.
Cumberland 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
458180.8993 N 2054991.4543 ywy
2/8/2022
6.Is(are)the well(s) Xi Permanent or Temporary f Certified dl Con actor Date
this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• [3Yes or X)No CAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofth record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19 (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(a)200'and 2®100') construction to the following:
10.Static water level below top of casing: 10.55 (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: 4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct push above, also submit one 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 Services Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: 1,addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructionl to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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