WQ0036210_More Information (Received)_20230710

WELL CONSTRUCTION RECORD_(GW-1
1. Well Contractor Information:
David Freedland
Well Contractor Name
4411-
NC Well Contracror Certification \umber
Bridger Drilling inc dba Carolina Drilling
Company Name `[� j� �j j� 2
2. Well Construction Permit #: 1' V lY 00 J ' 0
List all applicable well construction permits (t.e, UIC, C'OWIN, Str.rr Variant•e, etC.j
3. Well Use (check well use):
Water Supply Well:
3Agricuitural []Municipa)/Pubiic
]Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
3lndustrial/Commercial Residential Water Supply (shared)
"I— _ ..
Non -Water Supply Well:
Aquifer Recharge
Groundwater Remediation
Aquifer Storage and Recovery
Salinity Barrier
Aquifer Test
Stormwater Drainage
Experimental Technology
OSubsidence Control
Geothermal (Closed Loop)
Tracer
Geothermal (HeatingtCoolin Rentm)
Uther (explain under #21 Remz
4. Date Wel)(s) Completed: 6-1-2018
_ Well ID# MW-1
5a. Well Location:
Benchmark Ministries inc
-------------
FacilitylOwner Name
538 Hussey Rd, Robbins,
Facility IDT (if applicable)
NC 27325
Physical Address, City, and Zip
Moore County
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
{if well field, one latAong is sufficient)
35 28'33.39" 79
33 24 04"
FROM TO _- DF:SCRLPTIO'.t-�---
ft.
15_,0UTER:CAS1NG for multi -cased -cells A]"l l: i �t a
ficatiie
-I.- nM TO _DIAMETER THICK]
TTHICK---
MATERIAL:
0 ft 13 ft. in.
2
16. bN>N R'CASb~IG ORTTSBING eotfiet nai cltised3oo
FROM ; TO t DIAMETER IHI(_K�IE.SS _
ft. ft. in.
ft.- -- - __—_
� MATERIAL
17: S�iL1~EN-1
FROM 'I'O DIAMETER_
SLOTSIZE 1 THICKNESS
13 ft- 1 18 ft- in.
. NIATERfAL�
in.----�—-
1.5 ft. bentonite
0 rt. 1.5—
rr.
19 SA3�DIGRAVEL PA1QKiE' "fica 16
FROM i0 MATERIAL _ 1 EMPLACEMENT METHOD
11 ft. sang —
mptace
--
26. AIiFLLi14G LOG attach: tt"honalskeets`if nece3san? -
FROM _ I O " _UF SCRIPTIO\ (color, hardness, sod+rock hpe, £rain size. etc.)_
0 ft. 19 ft. Red to grey clay to sandy clay
ft — --ft. -- -- —
ft.
ft. i ft. -
22.
6, Is(are) the well(s)�!x Permanent or p Tem ors ry
Gnatu ofCenific —0m
ontractor —
Date
7. Is this a repair to an existing well: is a repair, fill out known Yes or x No
well construction
Kti .eignin this form, I herehv cxrtiJy that the well(s) $rvcv (were) constructed in accurdanre
with [SA NCAC 02C 0100 or 15A NCAC 02C'0200 Well (,'onstruction
information and explain the nature of1he
repair under #?[
repair remarks section or an the back of this form
.Standards and that a
copy of this record has been provided to the well owner.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
23. Site diagram or additional well details:
You may use the back of this;
construction. only 1 GW-1 is needed. Indicate TOTAL N-UMBER of wells
drilled: two
page to provide additional well site details or well
construction details. You may also attach additional
pages if necessary.
9. Total well depth below land surface: 1 @ 1 $ 1 19'
SUBMITTAL INSTRUCTIONS
.
(ft.)
For multiple welislist all depthvitdiferent(erample 3(g-00'and3(r�l00')
24a• For All Wells: Submit this form within 30 days of completion
10. Static water level below top of casing; +2
of well
construction to the following:
1(waterlevel iv above rasing, use " " (ft.)
Division of Water Resources, Information Processing Unit,
11. Borehole diameter. 3
1617 Mail Service Center, Raleigh, NC: 27699-1617
(in.)
12. Well construction method; direct push
24b. For Injection Wells; In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of
0-c. auger, rotary, cable, direct push, etc.)
completion of well
construction to the following.
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-I636
13a. Yield (,-pm) Method of test:
24c. For Water Supply & Injection Wells: In addition to sending the form to
I3b. Disinfection type: Amount:
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form UW -I North Carolina Department of Environmental
Quzlity - ,Rlvisioa of Water Resources
Revised '2-22-201 E