GW1-2022-10477_Well Construction - GW1_20221118

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WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information:
George R.Bridger 14.WATER ZONES
.
Well Contractor Name FROM TO DESCRIPTION
2393A 24 f z 40 f t
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.for multi cased wells OR LINER of a licable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER TiDCIINEs'
MATERIAL
CompanyName 0 % PO ft 2 in. sc,40 PVC
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: UIC Permit WI0400345 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC;County,State,Variance,etc.) NA ft. ft in.
3.Well Use(checkwell use): ft. ft in.
Water Supply Welt 17.SCREEN
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural DMunicipal/Public 20 ft 40 ft 2 in 1 .010 sch4o PVC
i Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft. ft in.
T
dustrial/Commercial Residential Water Supply(shared) 18.GROUT
i lion FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 27 ft neat inplace
I Monitoring DRecovery ft ft
Injection Well:
ft ft
I Aquifer Recharge ElGroundwater Remediatirm 19.SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test OStormwater Drainage 28 ft 41 ft Sand poured
I Experimental Technology OI Subsidence Control ft ft
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPnON color,haxdness,so0lrock type,grain size,etc
0 ft 0.75 ft Concrete
4.Date Wells Completed:10/17/22 Well ID#I WA 6 0.75 ft 1.25 ft
()Com P Gravel Base Coarse
5a.Well Location: 1� ft 40 M Dark Gray Silty Sand
Energizer Battery NCD000822957 ft ft
Facility/Owner Name Facility III#(if applicable) ft ft b6 5 V 1
419 Art Bryan Drive, Asheboro 27203 ft ft NOV 202?
Physical Address,City,and Zip ft fL
Randolph 7753756912 21.RENI[ARKS - _ (tni
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatilong is sufficient) 22.Certification-
35.776988 N -79.81819 W
10/17/22
6.Is(are)the well(s)E)Permanent or OTemporary Sivly..ofC. fied well Contraco 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: JDYes or EX No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repay,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 ofthisform. 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 ifnecessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exmnple-3@200'and 2@100) construction to the following:
10.Static water level below to of casing:28
P g= (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
HSA 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,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water Supply&Iniection 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