GW1-2021-02757_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT a'^. 14.WATER ZONES t
Well Contractor Name ­t� "t f 3--' FROM TO DESCRIPTION
A - 4226 y rt. ft.
S r « s 2021 ft.
NC Well Contractor Certification Number I
_ �1V1�1 15.OUTER CASING for multi-casediwells OR LINERlicable
GEOLOGIC EXP LO RATIONe1aGI1 `3+h0 1�1 mot! _.5, tg FROM TO DIAMETERUVv THICKNESS MATERIAL
i\ae on ff. ft. in.
Company Name
16.INNER CASING OR TUBING eoth'ermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,,Suite,Variance,etc) 0.0 ft- 13.0 ft' 2.0 I in. SCH 40 PVC
3.Well Use(check well use): ft. R. ! in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13.0 ft' 18.0 ft' 2.0 in. I .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. I
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rf. 80 ft. PORTLANDaENTONITE SLURRY
(Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 11.0 ft 18.0 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(Heat i ng/Cool ing Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/crock type,grRin size,etc.
0.0 ft 1.0 ft TOPSOIL
4.Date Well(s)Completed: 07/15/21 well ID# TMW2-3M 10 ft. 180 ft. BROWN SILT
ft. ft.
5a.Well Location:
MGP - DUKE ENERGY rt. ft.
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-8.0- 11.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufficient) 22.Certification:
805816.11 N 1703941.81 W 08/24/21
6.Is(are)the well(s): ❑Permanent or (9Temporary Signature ofCerti6ed Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.b200 Well Construction Standards and that a cony
if this is a repair,Jill out known well construction it formation and explain the nature of the ofthis record has been provided to the welhon•ner.
repair under 521 remarks.section or on the back oJ7his forms.
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-1 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: 18.0 (ft.)
For naltiple wells list a//depths ii(Wi ferent(example-3@200'and 1@100') Submit this GW-1 within 30 days of,well 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, to I/MSC;Raleigh,NC 27699-1617
/Jlrater level is above casing,use
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11.Borehole diameter: 6.0 (in,) 24b. For Infection 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-Loop 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 i Revised 6-6-2018