GW1-2021-02764_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
Well Contractor Name r I �t FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Numberr
_ �N� "its ^},rr�iuptl 15.OUTER CASING(for mulfi cagdl wells OR LINER if a licable
GEOLOGIC EXPLORATION 1t`ice Q1JI`` FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ft.
l6.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DI.AM ETER THICKNESS MATERIAL
list al!app/irahle well rnns'tructiwn penttiev(i.e.(/1('.('uunh•,.Stoic,Variance,ete.l 0.0 ft• 6•0 ft- 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. i in.
Water Supply Well: 17.SCREEN
❑Agricultural OMunicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 6.0 it. 11.0 ft. 2 0 i"' .010 SCH 40 PVC
ft ft.
❑Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
❑lrriaation ❑Wel Is>100,000 GPD FROM TO MATERIAL Et1IPLACEMENTMET14OD&AMOUNT
Non-Water Supply Well: 0.0 It. 1.0 ft- PORTLANo BENTONITE SLURRY
PJMonitoring ❑Recovery
ft. ft.
Injection Well:
❑A uifer Recharge
a ft• ft.
q $ ❑Groundwater Remediation
OA uifer Storage
a and Recovery 19.SAND/GRAVEL PACK ifa licable
q g q' ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test OStormwater Drainage 3.0 ft. 11.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothertmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilhncF type gnin size,etc.)
0.0 a• 1.0 ft• TOPSOIL/WOODS
4.Date Well(s)Completed: 07/1 3/21 Well ID# MW-17WT 1 0 ir. 11 Q fL BROWN SILT
Sa.Well Location: ft. fL
MGP - DUKE ENERGY ft. ft.
Facility/Owner Name Facility IDk(it•applicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260 fl• ft.
Physical Address,City,and Zip ft. R.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL_ 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Geld,one lat/long is sufficient) 22.Certification:
805938.11 N 1703954.18 W #
08/24/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By s-ignittg plus form,l herebv certiJv that the ii e//(ry was(were)construcied m accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A N(AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a cope
fflhis is a repair,fill out known well construction in(orn+ation arrd explain die nature ajrhe ofthis record has been provided to the it oivner.
repair under 421 remarkv section or on the hack ofdnis form.
23.Site diagram or additional well deiails:
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 ofwells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11.0 ft.
For multiple n•ells list al/depths ifdLtRrem(example-3@200'ond 2@100') ( ) Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: 7.5 (ft.) 24a• For All Wells: Original form to Division of Water Resources (DWR),
!1 uoler level is shove casing,use--" Information Processing Unit,1617 MSC,,Raleigh,NC 2 7699-1 6 1 7
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11.Borehole diameter: 6.0 (in,) 24b. For Infection Wells: Copy to D1NR;Underground Injection Control(ILIQ
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
counq'environmental health d, rtmentlof the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over1100,000 GPD:Copy to DWR,CCPCUA
m 13a.Yield ) Method of test:(gP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Qualit•-Division of Water Resources - _�
5 Revised G G_018