GW1-2022-07402_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1 y
1.Well Contractor Information:
KENNY SARGENT 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
A - 4226
ggg��� ft. ft.
NC Well Contractor Certification Number R�` 'Rf,
r 5."OUTER CASING-for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING cothermal closed-loop)
2.Well Construction Permit#: ROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cou 01 ', I6 kj6 c ` 0.0 ft. 55.0 ft. 2.0 in. SCH 40 PVC
`, 5
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. 15.0 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 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 10 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa 'licable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 15.0 It. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING COG attach additionid'sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soil/rocke, inin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 ft• ASPHALT/GRAVEL
4.Date Well(s)Completed: 02/14/22 Well ID# 3-34-MW-3 1 0 ft. 9 0 ft. BROWN SILTY SAND
5a.Well Location: 9.0 ft. 15.0 ft- BROWN SAND
HARVEY POINT FEDERAL FACILITY ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2835 HARVEY POINT ROAD HERTFORD 27944 ft. ft.
Physical Address,City,and Zip ft. ft.
PERQUIMANS 21.11EMARKS..
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 05' 46.23" N 760 19' 37.42" N AI,,,, � -r- 04/12/22
6.IS(are)the well(s): MPermanent 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 I19No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifdtis is a repair,fill out known well construction injormation and explain the nature ofthe ofthis record has been provided to the well onder.
repair under 421 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 1 GW-1 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: 15.0 (ft.)
hor multiple wells list al/depths ifd�erent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 4.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above caring,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.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
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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018