GW1-2022-03233_Well Construction - GW1_20220311

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 a "Sable
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 I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 rt' 25.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 rt• 35.0 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
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 19.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
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 23.0 ft- 35.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilh•ock type, rain size,etc.
0.0 It- 1.0 ft- GRASS/GRAVEL
4.Date Well(s)Completed: 10/27/21 Well ID# MW-52 1.0 ft. 6.0 ft• BROWN SILTY CLAY
5a.Well Location: 6.0 ft- 19.0 ft- BROWN SILTY SANDSTONE
HANSON AGGREGATES 19.0 ft 35.0 ft- BROWN SILTY PWR/MUDSTONE
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5103 DENFIELD STREET DURHAM 27704 ft. ft. MAR 1 202-?
Physical Address,City,and Zip
ft. ft.
DURHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 19.0-23.0 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.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fornt,!hereby cerltfy[hot the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!5No I5A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction infortttatton and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of'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 Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 35.0 (ft.)
For muhiple wells list all depths if different(example-3 a 00'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' 12.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ry'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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing'over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018
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