GW1-2022-08324_Well Construction - GW1_20220826

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Badger 14.WATER ZONES- z .
Well Contractor Name FROM TO DESCRIPTION
ft ft
2393-A
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING for could-cased wells OR LINER rt a lieable
Bridger Drilling FROM To DATER THICIINFSs MATERIAL
fL ft in.
Company Name
`:16.INNER'CASING OR.-TUBING eothermal dosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable-11 construction permits(e UIG County,State Variance,etc.) ft. ft in
3.Well Use(checkwell use): fL B- rn'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER S1.0TSM THICKNESS MATEMAT
❑Agricuhurd ❑MunicipaMblic n- 10 f 1.75 'n 1.010
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lndustrial/Commercial OR-denial Water Supply(shared) A8.GROUT
Ofirigation ❑Wells>100,000 GPD FROM To MATERIAL ':ACFMENf METHOD&AMOUNT
Non-Water Supply Well: o n. 8 fL
@monitoring ❑Recovery ft fL
Injection Well:
fL ft
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salim Barrier FROM
SANDlGRTO PACK da h'L&L ' •C
qcry ty FROM TO MATF•urnr. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8 ft 15 ft
❑Experimental Technology ❑Subsidence Control fL R.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPI'1ON color,hardness,wfll ck eta
0 � 1 ft- Sandy Clay
a.Date Well(s)Completed:July 14th �,� 1 fL ft Dark Brown Clay
5a.Well Location: 3 ft 5 ' Brown Sandy Clay
Brooks Distributing LLC 5 fL 9 RL Dark Brown Clay
Facility/OwnerName Facility III#(if applicable) 9 R 10 n Gray Clay
1400 Dr. Martin Luther Fling JR Blvd. Kinston, NC 10 13 fL Dark Brown Clay
Physical Address,City,and zip 13 fL 15 R' Beige Sandy Clay
Lenior ;21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification:
351635.51 N -773351.76 W Z� C:;!� 8/4/2022
6.Is(are)the well(s): ❑Permanent or STemporary Signature of Certi ed w 11 Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has beenprovided to the well owner.
repair under#21 remarks section or on the back ofthis 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 construction info
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dnlled'S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:15 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(erample-3@200'and 2@100)
(fL)
12.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing:
If water level is above caring,use"+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter•2 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
' Program,1636 MSC,Raleigh,NC 27699-1636
12 Well construction method:direct push
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the coT�u-nty gr)tereinsta4e4
FOR WATER SUPPLY WELLS ONLY: t'� `hsy z a
24d.For Water Wells producing over 100,00d Gib:'Cdp`'y to'bWR,CCPCUA
13a.Yield(gpm) Method of test.- Peffirt Program,1611 MSC,Raleigh,NC 27699-1611 2�22
Ali G 2
13b.Disinfection type: Amount:
Farm GW-1 North Carolina Department of Environmental Quality-Division of WaterResounzs Revised 6-6-2018