GW1-2021-02766_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES I
.,w.
Well Contractor Name + FROM TO DESCRIPTION
A - 4226
( L)1Sj ft. ft.
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION �E i3.ttK„���US�`��i�L,�1 FROMable
15. TO
CASING form D AMETEReIIs OT ICKN ESSa IIMATERIAL
fr. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.(//C,County,State,Variance,etc.) 0.0 ft- 25.0 ft' 2.0 in' SCH 40 PVC
3.Well Use(check well use): R. fr. in.
17.SCREEN
Water Supply Well:
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft. 30.0 ft- 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 19.0 ft' PORTLANDSENTONITE SLURRY
29Monitoring ❑Recovery ft. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 22.0 ft• 30.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under tl21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft. 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 07/1 3/21 Well ID# TMW1-2D 1.0 ft• 30.0 ft• BROWN SILT
Sa.Well Location:
30.0 ft• 31.0 fr' WHITE ROCK
MGP - DUKE ENERGY ft. ft.
Facility/Owner Name Facility ID#(if applicable)
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REII7ARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-9.0-12.0 FEET&30.0-31.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
805951.76 N 1703823.36 W �'� 08/24/21
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing This fornn,l hereby certify that the Ire//(s)was(were)c•onstrucied in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo /SA NCAC 01C.0/00 or 15A NCAC 02C.0100 Well Construction Srandardr and that a cops'
lflhis is a repair,fill out known hell construc•tio n itt(brnnation and explain the nature oJ'Ihe of'this record has been provided to the Drell owner.
repair under-'21 remarks section or on the back oJthis Jbrm.
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 ito 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
9.Total well depth below land surface: 30.0 (ft)
Far multiple we/Is/isi all depths iJ'dii erent(example-3 cr200'and 1 n/00') Submit this GW-1 within 30 days Of well completion per the following:
10.Static water level below top of casing: 7•5 (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I)u•nter lorel is above casing,use"=" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy toFDWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
i
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 over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 161 1 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 6-6.2018