GW1-2021-06960_Well Construction - GW1_20210505

1.W ell urntructur 1111ul'I11aUMI; -
Michael Radford .114.1WATER2ZONES',4""
Well Contractor Name FROM TO DESCRIPTION
4267A P rt. it.
s�
NC Well Contractor Certification Number
j 2�21 .15 O,UTER;GASING for:multi"e`ased;wells'UR;LINET ifa 6eable 9**
Bridger Drilling Enterprises, Inc. p,9yY X FROM TO DIAMETER THICKNESS MATERIAL
Company Name _ �t ��tt_,;` t„ (0 tt. 7 ft. 2 in. sch40 PVC
�,i t v;li t CIS &16INNER'C2i5ING ORTIJBING?` eottier'ineltlosed"-Ib6 ;
2.Well Construction Permit#: V�;GI"� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. tt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 37.SCREEN VMK494c,
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural E)Municipal/Public 7 tt 2z it 2 in.' .010 sch 40 PVC
:-)Geothermal(Heating/Cooling Supply) of Residential Water Supply(single)
ft. ft. in.
1 Industrial/Commercial 13Residential Water Supply(shared)
^;1$.-::GROUT*4 = . r., =!a` 7 .` k $ �' 4;"
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. t ft. Neat in place
E Monitoring Recovery
Injection Well: ILJ
uI Aquifer Recharge Groundwater Remediation
P
Aquifer Storage and Recovery Salinit Barrier 19.4SANDIGRA\NT0PAGK(iUa-`livable t
Y FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage s ft- 22 ft, Sand in place
Experimental Technology OSubsidence Control R. ft.
_.1 Geothermal(Closed Loop) OTracer :20.',DRILGING tiOG'attaeh`additiookl sheets if:necesss ` w
Geothermal(Heating/Cooling Return) _.' Other(explain under#21 Remarks) ft. it. > TION color,hardness,soil/rock e, rain sae,etc.
FROM TO DESCRIPTION
0 22 Gray Fine to Medium Sand
4.Date Well(s)Completed: 3/31/21 Well ID# OW 1
5a.Well Location:
Town of Surf City
Facility/Owner Name Facility ID#(if applicable) ft. ft.
173 Sarge Martin Road
Physical Address,City,and Zip tt. ft.
O11SloW
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
34 28 53.8305 N —77 32 57.8695 W
k7� 4/27/21
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well 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: E)Yes or XMNo with 15A NCAC 02C.0100 or 15A 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 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
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
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below to 6
P of casin g� (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
12.Well construction method:
HSA above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: i
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 SuDDIv& 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 to the county health department of the county
where constructed.