GW1-2022-03423_Well Construction - GW1_20220318

WELL CONSTRUCTION RECORD (GW-1) For Internal USe Only:
1.Well Contractor Information:
George R. Bridger 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. i
2393A ft. iL i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER THICKNESS MATERIAL,
0 ft- 4 ft. 2 in. sch 40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal 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): ft. ft. in.
I
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 4 ft- 14 ft. 2 in. oto sch4o pvc
I
Geothermal(Heating/Cooling Supply) �I Residential Water Supply(single) ft. g in.
Industrial/Commercial Residential Water Supply(shared) 18-GROUT
n Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.5 ft- 1.5 ft* neat inplace,<0.1 cyd
3 Monitoring [3 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVELPACK if a licab7is
Aquifer Storage and Recovery ©ISalinity Barrier FROM I To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 3 ft- 14 ft. sand prepack
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soittrock type in size,etc.
0 ft. 0.4 n Tan';and Gray Sand, Trace Cla .
4.Date Well(s)Completed:2/25/22 Well ID#MW-1
5a.Well Location:
Residence ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft. - '
16051 NC 210, Angier, 27501 fL ft.
Physical Address,City,and Zip ft. ft.
MAR 1
Johnston 21.REMARKS
County Parcel Identification No.(PIN) "f
"'�"Vp", �,,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification•
35 31 13.2 N -78 37 30.6 W
3/9/22
6.Is(are)the well(s) Xi Permanent or O1 Temporary Si VrAlg,Certifie Well ConInify
or Date
shis jorm,I hereby that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1J Yes or. xi No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this 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 1 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: 14 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 tt 100'and 2@100') construction to the following:
10.Static water level below top of casing: 5.1 (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: 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.) l
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1.3a.Yield(gpm) Method of test: 24c.For Water SUDnly&Injection Wells: In addition to sending the form to
the address(is) above, also subrhit'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to
the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016