GW1-2021-02753_Well Construction - GW1_20210901

I
I '.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
1.Well Contractor Information:
KENNY SARGENT �Y , ;47j't 14.WATER ZONES
Well Contractor Name �a.� -+��� e FROM TO DESCRIPTION
ft. ft. t
A - 4226
NC Well Contractor Certification Number Unit 15.OUTER CASING for multi-cased iwells OR LINER if a livable
GEOLOGIC EXPLORATIO ,,`u ki,3'I^'1`� '(' "t)0
1�1r FROM TO DIAMETER V THICKNESS MATERIAL
Company Name V'I`� _ �
n.
16.INNER CASING OR TUBING ebth'ermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) 0.0 @• 20.0 ft. 2.0 '" SCH 40 PVC
3.Well Use(check well use): R. tr. i in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 25.0 ft' 2.0 in.ii .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. !
❑lndustrial/Commercial ❑Residential Water Supply(shared) i
18.GROUT i
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 15.0 ft' PORTLAND BE NTONITE SLURRY
IBMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18.0 ft. 25.0 ft. 20-40 FINE SILICA SAND
OExperimental Technology ❑Subsidence Control
❑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,soillroek type,girain size,etc.
0.0 ft 1.0 ft. TOPSOIL
4.Date Wells)Completed: 07/15/21 Well ID# MW-14D 1.0 ft- 19.0 ft. BROWN SILT
5a.Well Location: 19.0 li 27.0 rt' PWR
MGP - DUKE ENERGY ft. rt.
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) BENTONIfE SEAL- 15.0-18.0 FEET/COLLAPSE 25.0-27.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
805810.19 N 1703941.19 W �". 08/24/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCcrtified Well Contractor Date
By signing this form,l hereby certify that the wells)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or ONO 1 SA NCAC 01C.0100 or ISA NCAC 02C.W00 Well Construction Standards and that a copy
If this is a 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 021 rentarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobil or Closed-Loop Geothermal Wells having the same You may use the back of this page t6 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
0
9.Total well depth below land surface: 25. (ft.)
hor multiple wells list all depths ifdi,/Jerent(example-3@200'and 1@100') Submit this GW-1 within 30 days 0(well completion per the following:
I
7.5 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
ljwater level is above casing,use"-" 4
11.Borehole diameter 6.0 (i"•) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 2 7699-1 636
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 i100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources '', Revised 6-6-2018