GW1-2021-02755_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT .) r 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION/ 9 11021
SCiI !\ i L ft. ft. `
A - 4226 1
NC Well Contractor Certification Number _
t . -t4 �r 15.OUTER CASING for multi-casedwehs OR LINER ifa ticable
GEOLOGIC EXPLORATI� + '" ~ i0 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ! in.
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.UIC.County,State,Variance,etc.) 0.0 ft. 14.0 ft- 2.0 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 14.0 1" 19.0 ft. 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tr. I ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 8.0 R. PORTLANDBENTONRE SLURRY
[NMonitoring ❑Recovery ft. ft.
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 11.0 ft. 19.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tr. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e, train size,etc.
0.0 fr. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 07/13/21 well ID# TMW2-2M 1.0 ft. 19.0 ft. BROWN SILT
5a.Well Location:
MGP - DUKE ENERGY ft. ft.
Facility/Owner Name Facility ID#(if applicable) fr. 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-8.0-11.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
805816.11 N 1703941.81 W �r 08/24/21
6.Is(are)the well(s): ❑Permanent or INTemporary Signature of Certified Well Contractor Date
J v signing this form,I hereby certify that the ivell(s)Was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No ISA NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Consiruciion Standards and that a copy
If this is a repair,Jill out known Ire//construction information and explain the native of the of this record has been provided to the trell'oirner.
repair under"2/remarks section or on the back ojthis formt.
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 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'i
9.Total well depth below land surface: 19'0 (ft.)
For multiple uve/h list al/depths ifdiJJerent(example-3@200'and 2@l00') Submit this GW-1 within 30 days Of;W¢II completion per the following:
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
/juater level is above casing,use"+"
11.Borehole diameter: 6.0 (in,) 241b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 2769971636
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 ov Ir 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018