GW1-2022-10473_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 DESCRWTION
2393A 24 ft 40 ft
It ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d'a licable
Bridger Drilling Enterprises, Inc. FROM To DIAMLM THICKNESS MATERIAL
0 ft 20 it 2 m' sch 40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed400
2.Well Construction Permit#: UIC Permit WI0400345 FROM To DIAMETER THICKNESS " MATERIAL
List all applicable well constructionpermits(1.a UIC,County,State,Variance,etc.) NA ft fit in.
3.Well Use(check well use): ft ft 1D
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERL4L
`i Agricultural QMunicipal/Public 20 ft 40 fc 2 'n' .010 sch40 PVC
`i Geothermal(Heating/Cooling Supply) D{Residential Water Supply(single) fL ft in.
`I Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 27 ft neat inplace
X Monitoring DI Recovery ft ft
Injection Well:
fit ft
!Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVELRACK(if applicable)
`I Aquifer Storage and Recovery OSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test U)Stormwater Drainage 28 ft 41 ft- Sand poured
-i Experimental Technology OSubsidence Control ft ft.
i Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecess
i Geothermal(Heating/Cooling Retina) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardne miuroek etc
0 ft 0.75 ft Concrete
4.Date Wells Completed:10/17/22 Well ID#OB-6 0.75 ft 1.25 it
()Com p Grave!Base Coarse
5a.Well Location: 1� ft 40 ft. ark Gray Silty Sand �` r._';! •o
Energizer Battery ft n
9 fY NCD000822957
Facility/Owner Name Facility ID#(if applicable) % ft
NOV
419 Art Bryan Drive, Asheboro 27203 ft ft
Physical Address,City,and Zip ft ft
Randolph 7753756912 21.REMARKS w
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-
35.76980 N -79.81820 W
10/17/22
6.Is(are)the well(s)EIPermanent or O{Temporary Sign&fire of fled well ContracM Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: C)Yes or E)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 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 (iL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing:28 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
FiSA 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 2 769 9-1 63 6
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