HomeMy WebLinkAboutGW1-2021-02762_Well Construction - GW1_20210901 f
WELL CONSTRUCTION RECORD(G_V)'.-le),r-yr* For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 2��t 14.WATER ZONES
Well Contractor Name
,5'=t-I• FROM TO DESCRIPTION
ft. ft.
A - 4226 {,r����s�ItJ
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NC Well Contractor Certification Number �y,U
15.OUTER CASING for multi-cased.wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
I. ft. in.
Company Name 16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 20.0 ft. 2.0 'n' SCH 40 PVC
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 25.0 ft' 2.0 in.
' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 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 fr' 14.0 fL PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storm%vater Drainage 17.0 fr• 25.0 ff 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. tr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/mck type, min size,etc.
0.0 fr• 1.0 ft• TOPSOIL/WOODS
4.Date Well(s)Completed: 07/13/21 Well ID# MW-17 1.0 rut• 25.0 fr. BROWN SILT
Sa.Well Location:
ft. ft.
MGP - DUKE ENERGY ft. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260 ft. ft.
Physical Address,City,and Zip
ft. rut.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 14.0-17.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification: y��wL""'l.`N! /'w•/`^rT
805937.57 N 1703963.82 W fJ/fIt' 08/24/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dtis form,1 hereby certify that Cite well(s)eras(were)constructed in accordance,rich
7.Is this a repair to an existing well: ❑Yes or PJNo 15A NC'AC 02C.0100 or 15A NCAC 02C;.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well consiruction infornmtion and explain the nature oj'ihe of dtir record has been provided to the,yell owner.
repair under 421 rentarks section or ail the back ofthis form.
23.Site diagram or additional wellldetails:
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: 25•0 (ft.)
For multiple wells list all depths/J'diiferent(example-3@200'and 2a/00') Submit this GW-1 within 30 days of well completion per the following:
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7.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
/jwater level is shore easing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in.) 24b. For Injection 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 over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018