GW1-2022-06843_Well Construction - GW1_20220720

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Gerald Eister 14:WATER ZONES i
FROM TO DESCR1PT1ONl
Well Contractor Name
2394 12 fr. 29 fr. fine to!med sand
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Bridger Drilling Enterprises, Inc. FROM TO DrAMETER THICKNESS MATERIAL
Company Name 0 ft- 15 ft 6 i in SCh 40 pvc
16.INNER CASING OR TUBING `eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.WC,County,State,Variance,etc.) 0 ft. 25 ft. 2 HL sch 40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 It. 30 ft 2 1D 0.10 SCh 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 25. ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS:GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 14 ft neat t6mmie
MMonitoring ❑Recovery ft. ft.
Injection Well:
_ ft ft
EAquife-r-Rec arg-fie- ❑Groundwaterr -ediafiot -- -
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery [!]Salinity Barrier FROM To I MATERIAL EMPLACEMENT bIETHOD
❑Aquifer Test ❑StormwaterDrainage 23 ft. 30 ft. torpedo
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sofurock a etc
.)0 tt• 5 ft sand
4.Date Wells)Completed: 6/14/22 Well ID# 5 ft 8 ft• sandy clay
5a.Well Location: 8 ft. 27 ft. fine to med sand
��j r!DfLn�- ,�/►QA'( 0�./� pZ�p01�j?(e7 27 ft 30 ft sandy clay
Facility/Owner Name Facility ID#(if applicable) ft ft
102 N. Walnut Fairmont, NC 28340 ft. ft
Physical Address,City,and Zip ft. it
Robeson County .21.RF.MARKS'
County Parcel Identification No.(PIN) 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification: ` {�-�'�yM ynl'' `I`
34.29.57 N -79.06.47 W twit. 7/5/2022
6.Is(are)the well(s): InFermanent or ❑Temporary Signat66 of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15ANCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out Imown ivell construction information and explain the nature ofthe ofthis record has been provided to theiiveil mvner.
repair under 921 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 construction info
construction,only I GW-1 is needed. In.irate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dried:t 24.SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: 30 (ft*) Submit this GW-1 within 30 days of well completion per the following:
For mulhple ivells list all depths ifdi ferenI(example-3@200'and 2@100�
10.Static water level below top of casing: 1224a. For All Wells: Original form to Division of Water Resources (DWR),
(ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
11.Borehole diameter: 6' (,n) 24b.For Iniection Wells:Copy'to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: mud rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health deparhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWI?,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc-�s, Revised 6-6-2018
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