GW1-2021-06962_Well Construction - GW1_20210505

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i.vven wouractur inturutauuu:
Michael Radford :.34?WATERkZONES 3--,.i .. H .r r 2 �7«" `BSc ,``• a .'.
Well Contractor Name °•I I—I FROM TO I DESCRIPTION
q q1 it. ft.
NC Well Contractor Certification Number 4 n
Io y 115:OUTER°CASINGi toi multi cased ells;OR 1 INER<iGa' lica'blei� ,
Bridger Drilling Enterprises, Inc. _ n s�4ntr'_.`�un ll FROM TO DIAMETER THICKNESS MATERIAL
(ll; 0 ft. ft. q in. sch40
Company Name PVC
P y 1U I w t7 t
nFROMTO
2.Well Construction Permit#: TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e, U1C,County,State, Variance,etc.) ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: �. S�' '' F•: sm I DIAMETER: I SLOTRT7,F-7 THICKNESS MATERIAL
Agricultural DMunicipal/Public 7 ft. 22 ft' 2 in. 010 sch40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. tt. in.
_1 Industrial/Commercial 13Residential Water Supply(shared) �g GROUTS
Irrl atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft.
Neat in place
xl Monitoring _i Recovery
Injection Well:
ft. ft.
`i Aquifer Recharge DGroundwater Remediation
I_ Aquifer Storage and Recovery OSalinitY Barrier 19+SANDIGRA'YELIP.ACK ifii`iili4lble` B' k
FROM TO MATERIAL EMPLACEMENT METHOD
__I Aquifer Test oStormwater Drainage 5 ft- 22 ft• Sand in place
Experimental Technology Subsidence Control
_I Geothermal(Closed Loop) Tracer '20'DRIELINGT,L'OG"attach additional sheets'ifnecessa'
I !Geothermal(Heating/Cooling Coolin Return FROM TO DESCRIPTION color,hardness,soil/rock a rain size,etc.
( g/ g ) _1 Other(ex lain under#21 Remarks
0 ft. 11 ft. Gray Fine to Medium San
4.Date Well(s)Completed: 3/31/21 Well ID# OW 2 11 ft. 22 ft.
Dark Gray Sandy Clay
5a.Well Location:
Town of Surf City ft. ft.
Facility/Owner Name Facility ID#(if applicable)
173 Sarge Martin Road
Physical Address,City,and Zip ft. ft.
Onslow it RE-MARKS: ;. �;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient)
22.Certification:
34 28 53.8934 N -77 32 57.9342 w
4/27/21
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JqNo 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"Ito provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22 (ft•) 24a. For All Wells: Submit this:form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below to of casin 2
P g� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,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
12. HSA above, also submit one copy of this form within 30 days of completion of well
(i.e.Well construction method:.auger,rotary,cable,direct push,etc.) construction to the following: ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suonly& Infection 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 tol the county health department of the county
where constructed.
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