GW1-2022-01872_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT .� �•; ` � 14.WATER ZONES
} FROM TO DESCRIPTION
Well Contractor Name i
ft. ft.
A - 4226 FEB 16 202? ft. ft.
NC Well Contractor Certification Number e�e1 15.OUTER CASING for multi-cased wells OR LINER if a licoble
GEOLOGIC EXPLORATION lftj�'9tfti'1 IPfIE�W""'�URi1 FROM TO DIAMETER THICKNESS MATERIAL
�;013 0.0 ft. 109.0 ft- 6.0 I in. SCH 80 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0.0 rf 127.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in,
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 127.0 ft, 137.0 ft• 2.0 in., .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft tt in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 108.0 ft. PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery 0.0 ft' 109.0 ft' PORTLANDBENTONITE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage 121.0 ft- 139.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence 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 TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 01/11/22 Well ID# CCR-16DB 1.0 ft. 22.0 1" BROWN CLAY
5a.Well Location: 22.0 ft. 67.0 ft' BROWN SILTY SAND
BUCK STEAM STATION 67.0 rt• 980 rt• BROWN SILTY SANDY PWR
Facility/Owner Name Facility ID#(ifapplicable) 98.0 rt• 139.0 rt• BLACK ROCK
1555 DUKEVILLE ROAD SALISBURY 28146 ft. ft.
Physical Address,City,and Zip
ROWAN 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 108.0-121.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
3So 42' 43.01" N 800 22' 05.52" W �'~ 01/19/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0100 or 15A NCAC QC.0200 Well Construction Standards and that a copy
lrlhis is a repair,fill oul known well construction iglbrmation and explain the nature of the of this record has been provided to the hell owner.
repair under it21 rentarks section or on the back gjthis 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 137.0
For multiple wells list a//depihs ifdijj�reni(example-3 rt 100'and 1 a/00') Submit this GW-1 within 30 days of well completion per the following:
48.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f waler level is above casing,use".
(•Q 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter. (in.) 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018
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