GW1-2022-01871_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
p Well Contractor Name FROM TO DESCRIPTION
qP� ,y F
ft. ft.
NC Well Contractor Certification Number FEB 1 (,V 20ZZ 15.OUTER CASING for multi-cased wells OR LINERlivable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
r.- �^;��x•inq unf
ft. fr. in.
Company Name t ' ^+[jta�t�itJl J
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable hell construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft. 60.0 f[. 2.0 in. SCH 40 PVC
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 60.0 ft' 70.0 ft, 2.0 'n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 51.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 55.0 fr• 70.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rrock type,grain size,etc.
0.0 ft. 1.0 ft. GRASSffOPSOIL
4.Date Well(s)Completed: 01/1 1/22 well ID# CCR-16SB 10 rt. 22.0 ft BROWN CLAY
5a.Well Location: 22.0 ft. 67.0 ft' BROWN SILTY SAND
BUCK STEAM STATION 67.0 ft 70.0 ft BROWN SILTY SANDY PWR
Facility/Owner Name Facility]DO(if applicable) ft. ft.
1555 DUKEVILLE ROAD SALISBURY 28146 ft. ft.
Physical Address,City,and Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 51.0-55.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 42' 43.01" N 800 22' 05.52" W �'� 01/19/22
6.Is(are)the well(s): CEPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hv.signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I15No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/(this is a repair,Jill out known well construction information and explain the nature of ilhe of this record has been provided to the well owner.
repair under't1l remarks section or on the back oJ'ihis 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 Ovet in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70.0 (ft.)
l,or multiple wells list all depths iJ'dif)ereni(eromple-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 48.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/J'water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open'-Loon 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 producinelff 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:
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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