GW1-2022-10492_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
George Bridger 14..WATER ZONES
Well Contractor Name FROM I TO DESCRIMON
2393-A 6 ft- 30 fL
ft ft
NC Well ConhactorCeRificationNumber 15.OUTER CASING(for TE I:asedwells OR LINER d.n Gcable
Bridger Drilling Enterprises, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name
UIC#WIO8OO5Z8 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERML
List all applicable well construction permits(1.e.UIC,County,State,Pariance,etc) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUM THICKNESS MATFJUAL
❑Agricultural ❑MunicipaWablic tt ft in.
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ft It. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
oirrigatiou ❑Wells>100,000 GPD FROM TO MATERML EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery ft it
Injection Well:
ft (t
❑Aquifer Recharge CJGroundwater Remediation
19.SAND/GRAVEL PACK d applicable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL E"I ACE KENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. (t
❑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 ft ft TO DESCRIPTION rotor hardy soilhnek o " eta
4.Date Well(s)Completed:10/4/22 wen ID# N/A M ft
5a.Well Location: ft ft.
Fo Madt-mMiele-endlmMryBtod®eWPmprOm DSCA ID#65-0001 � (t �`�.'.a:�n...���.� �V3
Facility/Owner Name Facility ID#(if applicable) ft ft
2022
3750 Oleander Drive, Wilmington, NC 28403 ft ft i
Physical Address,City,and Zip ft ft IMGmns:iD;l
New Hanover 21.RENIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification-
171013.833 N 2331802.645 W e8 11/4/2022 .
6.Is(are)the well(s): ❑Permanent or InTemporary Signs ol'Certifi Well Contractor v Date
I 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 ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown 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 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:m' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17@30 (ft)
For multiple wells list all depths ifd fferent(example-3@200'and 2@100D Submit this GW-1 within 30 days of wen completion per the following:
10.Static water level below top of casing: 6 (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
11.Borehole diameter: 2 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: direct push
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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