GW1-2022-10471_Well Construction - GW1_20221118

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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
2393A 24 ft. 40 fL
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER rf a ticable
Bridger Drilling Enterprises, Inc. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 20 fL 2 ra sch 40 PVC
Compa�rName - -
UIC Permit W10400345 16.INNERCASINCORTURINc cathermeleloseaann
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,County,State,PanancG etc.) NA ft ". in
3.Well Use(check well use): rL I ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_I Agricultural DMunicipal/Publie 20 fL 40 ft 2 1°' .010 sch40 PVC
)Geothermal othe:rmal(Heating/Cooling Supply) OResidential Water Supply(single) M fL in.
J Industdal/Commercial EIResidential Water Supply(shared)
18.GROUT
11 1-igatio. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f[ 27 fL neat inplace
Monitoring Recovery ft. ft.
Injection Well:
ft ft.
!Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK tf a livable
-i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test OStormwater Drainage 28 fL 41 ft. Sand poured
-i Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) FROM TO DESCRIPTION mlor,birdness,soNrack rain size,etc.
0 M 0.75 f[ Concrete
4.Date Well(s)Completed:10/17/22 Well ID#IWA 5 075 fL 125 fL Gravel Base Coarse
Sa.Well Location: 1ss fL 40 fL Dark Gray SIty Sand
Energizer Battery NCD000822957 M ft' °z
Facility/Owner Name Facility ID#(if applicable) M ftrl !
419 Art Bryan Drive, Asheboro 27203 f` �'"V 1 ��
Physical Address,City,and Zip fL ft. r
21.REMARKS
Randolph 7753756912
,r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fatilong is sufficient) 22.Certification:
35.776987 N -79.81824 W
�2��� 10/17/22
6.Is(are)the well(s)oPermanent or OTemporary Signaturew Ccrtifi Well Contractor v Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E)No with I5A NCAC 02C.0100 or I5A NCAC 02C_0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dnllech SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing:28 (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: 8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
HSA 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 Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In 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 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