GW1-2022-10475_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 32 ft 45 %
fa ft
NC Well Contractor Certification Number 15.OUTER CASING for mold-cased wells OR LINER tf a livable
Bridger Drilling Enterprises, Inc. FROM To DIAMMR TLHCIQVESS MATERIAL.
0 ft 44 ft 2 ra sch 40 PVC
Company Name
�{ 36.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: UIC Permit W10400345 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fie.UIC,County,State,Variance,etc.) NA % % in.
3.Well Use(check well use): ft M fn
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
-i Agricultural [)Municipal/Public 24 fL 44 fL 2 in. .010 sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fL in.
dustrial/Commercial Residential Water Supply(shared)
18.GROUT!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 31 fL neat inplace
X Monitoring DRecovery ft %
Injection Well:
ft ft
3 Aquifer Recharge [)GroundwaterRemediation
_ 19.SAND/GRAVEL PACK if applicable)
I Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT NIETHOD
:]Aquifer Test [)Stormwater Drainage 22 ft 44 ft• Sand poured
-!Experimental Technology I MSubsidence Control fL ft
RGeotbermal
Geothermal(Closed Loop) [)TraCer 20.DRILLING LOG attach additional sheets if necessa(Heating/Cooling Return) 1 Other(explain under#21 Remadcs) FROM To DESCRIPTION color,hoidnen,millroek etc.
0 ft 1 fL Concrete
4.Date Well(s)Completed: 10/17/22 Well lD#OB-8 fL ft
5a.Well Location: 1 ft 45 B' Tan and Dark Gray S1ty Sand
Energizer Battery NCD000822957 ft ft
Facility/Owner Name Facility lD#(ifapplicable) ft ft
419 Art Bryan Drive,Asheboro 27203 % ft
Physical Address,City,and Zip ft & I Y 0 V 1 8 Z 0 Z7
Randolph 7753756912 21.REMARKS
County Parcel Identification No.(PIN) Uru..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.76947 N -79.81831 W
�. 10/17/22
6.Is(are)the well(s)OPermanent or OTemporary Signature dftertified Wen Contractor 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: [)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repay,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 if necessary.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 44 -(fL) 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@100D construction to the following:
10.Static water level below top of casing:32 (ft) Division of Water Resources,Information Processing Unit,
If water 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
HSA above,also submit one copy of this fora!within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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