GW1-2021-02760_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ?°►
KENNY SARGENT
..� 14.WATER ZONES ! i
s�•v q Well Contractor Name FROM TO DESCRIPTION
� Aoy1 ft. ft. I ',
A - 4226 c,tp t� L L ft. ft. P� ,
��i(i]�3Zlt
NC Well Contractor Certification Number yrr,G@ 3. 15.OUTER CASING for multi-cased weIts)OR LINER if a licable
GEOLOGIC EXP LO RATIO htttWO�r--, CC''�'t100 FROM TO DIAMETER THICKNESS MATERIAL
f ,in.
Company Name f
16.INNER CASING OR TUBINGeothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) 0.0 ft. 6.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER!1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 fr• 11.0 f" 2.0 t"' .010 SCH 40 PVC
OGeotherinal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. R. in.I
❑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 fr. 1.0 ft' PORTLANDaENTONRE SLURRY
❑Monitoring ❑Recovery ft. fr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft. 11.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology OSubsidence Control ft. R. ',
❑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,hardne55,soiUrock e, min size,etc.
0.0 ft. 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 07/14/21 Well ID# TMW1-3S 1.0 fr. 11.0 fr' RED/BROWN SILT
Sa.Well Location:
ft. ft.
MGP - DUKE ENERGY fr. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip
fr. 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]at/long is sufficient) 22.Certification:
805945.58 N 1703893.09 W A� ' _ 08/24/21
6.Is(are)the well(s)• ❑Permanent or IETemporary Signature of Certified Well Contractor Date
By.signing this form,I hereby certify that the trell(s)tros(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 01C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction hijbrnmtion and explain the nature gjihe of this record has been provided to the well owner.
repair under e21 remarks section or on the back ofthis fornh.
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 ifnecessan,.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11.0 (ft.)
For multiple wells list all depths iif'dii fereni(example-J a 200'and 2 rer l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7.5 (ff.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
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Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1j'water level is above casing,use"+
IL 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018