GW1-2022-06872_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gerald Eister 14.WATER ZONES
FROM TO I DESCRIPTION
Well Connector Name
2394 12 ft- 29 fL fine to load sand
ft. It.
NC Well Contractor Certification Number 15.OUTER CASING,for multi cased wells OR LINER if a livable
Bridger Drilling Enterprises, Inc. FROM To DIAMETER THICIINFSS i MATERIAL
Company Name 0 fL 115 ft 6 1° I sch 40 1 pvc
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNUS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variancg etc) 0 ft 25 ft 2 in. sch 40 1pvc
3.Well Use(check well use): rL ft in.
17.SCREEN
Water Su Well: _
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 fz 30 fL 2 in- 0.10 sch 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 25 ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi ion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMIIVTME HOD&AMOUNT
Non-Water Supply Well: 0 ft- 14 ft neat trimmie
Inmonitoring ❑Recovery ft. - ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Agnifer Storage and Recovery OSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StoffiwaterDiainage 23 It 30 ft torpedo
❑Experimental Technology ❑Subsidence Control M ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM . TO . . DESCRIPTION color,hurda son/roek eta
0 ft 5 ft sand
- .,
4.Date Well 6/14/22
ft
s)Completed: Well ID# 5 8 sandy clay f .
5a.Well Location: 8 ft 27 fL fine to med.sand
27 ft 30, ft. sandy clay
Facility/owner Name Facility 1D#(if applicable) fL ('1'.'tip? y, j
102 N. Walnut Fairmont, NC 28340 P Cit
Physical Address;City,and Zip
W, . fi,
Robeson County 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.29.57 N -79.06.47 W "4" 7/5/2022
6.h(are)the well(s): Permanent or ❑Temporary _ Siguat66 of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If Ibis is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells ( in Remarks Box).You may also attach additional pages if necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
r
9.Total well depth below land surface: 30 (fG) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
1`2t 24a. For'All Wells: Original font to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Info
rotation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ..
6' 24b.For Injection Wells:
Copy td'DWR,Underground Injection Control(IUC)
11.Borehole diameter. (1) Program,1636 MSC,Raleigh,NC 27699-1636
12.(ix:auger,rotary,cable,dvect push,etc.)Well construction method: mud rotary24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the'
(i.c - county environmental health department of the county where installed ..
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018