GW1-2021-02752_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name ' FROM TO DESCRIPTION
yak• ft. ft.
A - 4226
NC Well Contractor Certification Number
r mill I(�tJ�1�� 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name ' J
t6.INNER CASING OR TUBING eothermal closed-loop)
2.WCII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable wel/construction permits(i.e.UIC,County,State.Variance,etc.) 0.0 ft' 5.0 h' 2.0 "' SCH 40 PVC
3.Well Use(check well use): in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 10.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTLANDBENTONRE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft. 10.0 ft' 20-40 FINE SILICA SAND
❑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 To DESCRIPTION color,hardness,soil/rvck type,grain size,etc.
0.0 ft. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 07/1 2/21 Well ID# MW-13WT 1.0 ft• 10.0 ft. BROWN SILT
5a.Well Location:
MGP - DUKE ENERGY ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
805799.00 N 1703899.88 W �� 08/24/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCe"ified Well Contractor Date
By signing this form,l hereby certify that the trell(s)Bras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 01C.0100 or I5A NCAC 01C.0200 Well Construction Standards and that a copy
if this isa repair,fill out known 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 of this form. i
23.Site diagram or additional wellidetails:
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 I 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: 10.0
For multiple wells list all depths ifd fjerent(example-3(a 100'and 2 a/00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7•5 (ft') Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lJ.water level is above casing,use
24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6.0 (in.)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departlrient of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh',NC 27699-1611
I
13b.Disinfection type: Amount:
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
f