GW1-2022-01781_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
George R. Bridgeer 14.WATER ZONES
Well Contractor Name r FROM TO DESCRIPTION i /
2393A f`a It. ft
NC Well Contractor Certification Number FEB 14 2RZ 15.OUTER CASING for multi cased wells OR LINER if a livable
Bridger Drilling Enterprises, Inc. FROM To DLIMETER TMCKNESS MATERIAL
0.5 ft• 9 ft• 2 1° sch 40 pvc
Company Name 16.INNER CASING OR TUBING eotherma]closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICK L.
NESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public 9 ft. 79 ft. 2 in. .010 scn 40 pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
J Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.75 ft. 6 ft. neat inplace,<0.1 cyd
xl Monitoring [Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remediation 19.SAND/GRAVEL PACK if appiivable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 7 ft 19 ft sand Prepack and tremie
_1 Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
J Geothermal(Heating/Cooling Return J Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soittrock in size,etc
0 ft. 19 IL Tan Fine to Medium sand,
4.Date Well(s)Completed: 1/12/22 Well ID#MW-$ ft. ft.
5a.Well Location: ft. ft.
Naman Judson, LLC ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
520 Judson Church Road, Fayetteville
Physical Address,City,and Zip
ft. ft.
Cumberland 21.REMARKS
i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
458086.9866 N 2055096.2026 N
2/8/2022
6.Is(are)the well(s) Xl Permanent or OTemporary �;5A
o rtified Well Contractor Date
g 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 Xi No NCA(C 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 to provide additional well site details or well
construction,only I 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: 9 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3(200'and 2(a31001 construction to the following:
10.Static water level below top of casing: 10.41 (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: 4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct push 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 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016