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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
KENNY SARGENT 14.WATER ZONES . >
Well Contractor Name FROM TO DESCRIPTION
ft. ft. '
A - 4226
ft. ft.
NC Well Contractor Certification Number ,15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 n.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft• 5.0 ft• 2.0 I in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 20.0 ft' 2.0 in*: .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT '
Oh-ligation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft• PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage 4.0 ft• 20.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 11/22/21 Well ID# MW-6A 1.0 ft. 4.0 ft' BLACK SILTY SAND
5a.Well Location: 4.0 ft. 9.0 ft. BROWN SILTY SANDY GRAVEL
SHERIFFS OFFICE 9.0 ft• 20.0 ft. BROWNS, SANDY SILT
Facility/Owner Name Facility tDii(if applicable) ft. ft. 1 lYlHrf 1 9og7
300 RODNEY ORR BYPASS ROBBINSVILLE 28771 ft. ft. • L C -
Physical Address,City,and Zip ft. ft.
GRAHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 3.0 4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one!at/long is sufficient) 22.Certification:
35° 19' 31.47" N 83° 48' 08.90" W 91 . .kw7lr. 12/01/21
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we/l(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 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well,details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-l 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: 20'0 (ft.)
For multiple wells list all depths ifdiifferent(example-3�00'and 2 r�i!00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (5.0 ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" 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
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