GW1-2022-03230_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES j
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
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.1/1C,County,State,Variance,etc) 0.0 rf 75.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 75.0 n. 90.0 rt. 2.0 in. 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. B. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 l" 69.0 ft' PORTLAND BENTONITE SLURRY
(Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 73.0 ft. 90.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heat ing/Cool ing Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin sim,etc.
0.0 rr• 1.0 rr• GRASS/TOPSOIL
4.Date Well(s)Completed: 11101121 Well ID# MW-56 1.0 rt 18.0 a• BROWN SILTY CLAY/GRAVEL
5a.Well Location: 18.0 rr. 90.0 rt' BROWN SILTY PWR/MUDSTONE
HANSON AGGREGATES ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
5103 DENFIELD STREET DURHAM 27704 ft. rt.
Physical Address,City,and Zip ft. ft.
DURHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-69.0-73.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 04' 19.99" N 780 53' 29.62" W 11/11/21
6.Islam)the well(s)' [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(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
1f this is o repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 remarks.section or on the back q/this form.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90.0 (ft.)
For multiple wells list all depths ifdierent(example-3@a 200'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 55.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is shove 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018