GW1-2022-03235_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
a. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM '1 DIAMETER THICKNESS MATERIAL
tt. R. 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 ft. 25.0 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 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
❑Irrl atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 19.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑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 I EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage 23.0 ft' 35.0 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(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/rock type,ginin size,etc.
0.0 ft• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 1 O/28/21 Well ID# MW-50 1.0 ft 20.0 fr' BROWN SILTY CLAY/GRAVEL
5a.Well Location: 20.0 fr' 35.0 ft' BROWN SILTY PWR/MUDSTONE
HANSON AGGREGATES ft. ft. �=
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. I ° -- `- -• y.-
5103 DENFIELD STREET DURHAM 27704 ft. ft. 2
Physical Address,City,and Zip ft. ft.
DURHAM 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL19.0 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 form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill our known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of Ihis 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 1 GW-1 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: 35.0 (ft.)
For multiple wells list all depths'if different(example-3(200'and 2 ae100') 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),
10.Statter ic
is above casing, w o •• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifo11.Borehole diameter: 6.0 (in.) 24b. For Infection 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
l
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