GW1-2022-10399_Well Construction - GW1_20221116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Radford 14.WATER ZONES.:
Well Contractor Name FROM TO OFSCRIPrION
ft. ft
4267-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER d a licable
Bridger Drilling FROM TO DIAMETER THICKIVFSS MATERw,
ft ft in
Company Nam 16.INNER CASING OR TUBING eothermal closed4oa
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.b7C,County,State,Variance,eta) ft. ft in.
3.Well Use(check well use): ft ft to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft 5 ft 2 in. joint flush
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 0 ft. in.
❑lodustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
0hrigation ❑Wells>100,000 GPD FROM To MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft 15 ft portand cement
1*-Monitoring ❑Recovery ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑ Cos Loop ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRD'fION color,hanlness,soWrock type,grain sizai eta
0 ft 6 ft brown sandy clay
4.Date Welt(s)Completed: 11/4/22 wen ID#MW2 6 ft 12 ft orange sandy clay
5a.Well Location: 12 ft 15 fL gray silty clay
Ashton Woods ft ft
Facility/Owner Name Facility lD#(ifapplicable) ft ft �- - yypp- tl i
Hasentree Way and Sandytree Lane Wake Forrest,NC 27587 ft ft
Physical Address,City,and Zip ft ft NOV 16 2042
Wake 21.REMARKS
ihufil i" ch t m;. Alai 4-
County Parcel Identification No.(PIN) tl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification-
36.00.14 N -78.35.51 W
/� u 1119/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature ofCcrtified well Contra/olr 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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: 10.4 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program;1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the-
(ie.auger,rotary,cable,direct push,etc.) 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
Permit Program;1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 .
l ,