GW1-2022-10472_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 ft
ft ft ,
NC Well Contractor Certification Number 15.:OUTER CASING for mniti<aced wells OR LINER d a licable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER THICIINESS MATERIAL
0 ft 20 ft 2 rn• sch40 PVC
CompanyName
16.INNER-CASING OR TUBING(geothermal closed-loop)•''" - '
2.Well Construction permit#: UIC Permit WI0400345 FROM I TO DIAMETER THICHIVFSS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) NA ft ft in.
3.Well Use(checkwell use): it ft in.
Water Supply Well: 17.-SCREEN
FROM TO DIAMETER SLOT SIZE THICIINESS MATERUL
-i Agricultural DMunicipal/Public 20 ft 40 2 in .010 sch40 PVC
i Geothermal(ReatinglCooling Supply) DResidential Water Supply(].n
ft ft in.
_i Industrial/Commercial Residential Water Supply( 18.GROUT
i Irri lion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 27 ft neat inpiace
X Monitoring Di Recovery ft ft.
Injection Well:
n ft
Aquifer Recharge Groundwater Remediation
'19.SAND/GRAVEL,PACK da livable
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
31 Aquifer Test DStormwater Drainage28 ft- 41 it- Sand poured
I Experimental Technology OI Subsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional'sbeets if neces = -
FROM TO DESCRIPTION color hardness,wWmek rain ' etc
I Geothermal(Heating/Cooling Return) Other(explain under 921 R
0 ft 0.75 ft Concrete
4.Date Well(s)Completed: 10/17/22 Well ID#OB-5 0.75 fL 125 f Gravel Bass Coarse
5a.Well Location: ,u R• 40 B• Dark Gray Silty Sand, .,,-
Energizer Battery NCD000822957 ft ft. vo 1,
Facility/Owner Name) Facility ID#(ifapplicable) ft ft.
419 Art Bryan Drive, Asheboro 27203 ft. ft No V10Z2
Physical Address,City,and Zip ft ft
Randolph 7753756912 21•xEnlnxxs County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification:
35.76953 N -79.81840 W
��� � 10/17/22
6.Is(are)the well(s)EIPermanent or OI Temporary Si tore ofCKtified well Contra or 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: [3Yes or EJNo with 15ANC4C 02C.0100 or 15ANCAC 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 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (it-) 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 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 8 (in.) 24b.For Injection 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