GW1-2022-03234_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
rt. rr.
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. I ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trch construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft- 25.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
I7.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft' 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 atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 f. 19.0 ft' PORTLAND BE NTONRE SLURRY
MMonitoring ❑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 ❑Stormwater Drainage 23.0 ft. 35.0 fit- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(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,soil/rock type,grain size,etc.
0.0 ft. 1.0 ft. GRASS/GRAVEL
4.Date Well(s)Completed: 10/28/21 Well ID# MW-51 1.0 ft. 9.0 ft. BROWN SILTY CLAY
5a.Well Location: 9.0 rt. 22 0 ft• BROWN SILTY SANDSTONE
HANSON AGGREGATES 22.0 ft• 35.0 fL BROWN SILTY PWR/MUDSTONE
Facility/Owner Name Facility ID#(if applicable) ft. ft. ---
5103 DENFIELD STREET DURHAM 27704 ft. ft. AR 1 2029-
Physical Address,City,and Zip ft. ft.
DURHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfESEAL,- 19.0-.23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certification:
360 04' 19.99" N 780 53' 29.62" W �"� 11/11/21
6.Is(are)the well(s): IDPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,/herehy certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!5No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a cony
1f this is a repair,Jill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 811 remarks.section or on the back ofthis 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'Sce 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 multiple wells list all depths ifdiffirem(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
12.0 24n. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is abore casing,use
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
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells nroducinQ[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:
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resource`s Revised 6-6-2018