GW1-2022-10474_Well Construction - GW1_20221118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George R.Bridger 14.'WATER ZONES,
Well Contractor Name FROM TO DESCRHMON
2393A 24 ft 40 ft
fL ft.
NC Well Contractor Certification Number '15.OUTER CASING for multi cased wells OR LINER rf a livable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER THICE1•iF,SS MATERIAL
p ft 20 ft. 2 in. sr1r40 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: UIC Permit WI0400345 FROM TO DIAMETER THICIINESS MATERIAL
List all applicable well construction permits(Le.UIC County,State,Variance,etc.) NA M ft. in,
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICIGWSS MATERiAi.
i Agricultural OMunicipal/Public 20 fL 40 ft 2 in. .010 sch40 PVC
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL & in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 27 ft. neat inplace
x Monitoring DRecovey ft ft.
Injection Well:
ft ft
I Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL-PACK if applicablel
1 Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStmmwater Drainage 28 ft 41 ft- Sand poured
Experimental Technology DSubsidence Control ft fL
1 Geothermal(Closed Loop) DTraccr 20.DRILLING LOG attach additional sheets if necessary)
- Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIMONcolor hardness,wfl/rock rain size,etn
0 % 0.75 ft Concrete
4.Date Well(s)Completed:10/17/22 Well ID#OB-7 0.75 ft 125 fL Gravel ease coarse
5a.Well Location: 1.25 ft 40 ft. Dark Gray Sflty Sand ;_ •q q;a
Energizer Battery NCD000822957 ft fL - �-5 ,ag3
Facility/Owner Name Facility lD#(f applicable) ft ft ^ 1
419 Art Bryan Drive,Asheboro 27203 ft ft. -
Physical Address,City,and Zip ft ft
n
Randolph 7753756912 :21.REMARKS C-5.73;.%l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
35.76964 N -79.81822 W �
10/17/22
6.Is(are)the well(s)OPermanent or OTemporary Signatur&6fCcrtifica 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: OYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature afthe copy ofthis 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3ta3200'and 2@100) construction to the following:
10.Static water level below top of casing:28 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: $ (in.) 24b.For Injection Wells: In addition to sending the fort to the address in 24a
12.Well construction method:
FiSA 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:
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 Supply&Injection 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