GW1-2022-07403_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
A - 4226 ft. fr.
ft. ft.
NC Well Contractor Certification Number �. ,..,..� a` .15.OUTER CASING for multi-cased wells OR LINER if a ilicable
GEOLOGIC EXPLORATION , a FROM TO DIAMETER THICKNESS MATERIAL
ft.
Company Name MAY 3 0 2022
16.INNER CASING OR TUBING( eothermal closed-too
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Cow�tp,�Stair;•Rp�iagce,etc) S,� Q,Q ft. 5.0 f- 2,0 in. SCH 40 PVC
If1�Jt r t.. :,)_",.. Uri
3.Well Use(check well use): D. 01 t1 1.'L31X: fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 rt• 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 ft- 1.0 ft' PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well: D. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft- 15.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional streets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soft/rock type,grain size,etc.
0.0 tt• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 02/14/22 Well ID# SSA-MW-3 1.0 fr. 4.0 ft- BROWN SILTY CLAY
5a.Well Location: 4•0 ft. 9.0 t" GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 9.0 ft- 15.0 ft- BROWN SAND
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.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
360 05' 47.22" N 760 19' 36.23" N 0,lnvt I1„�"�" 04/12/22
6.IS(are)the well(s): MPermanent or ❑Temporary Signature ofCertifred Well Contractor Date
Hy signing this firm,I hereby certify that the srell(s)u•as(here)constructer!in accordance with
7.Is this a repair to an existing well: ❑Yes or (END 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stondar(h and that a copy
If this is a repair,fill out known ire/l construction hi6brination and explain the nature of the of this record has been provided to the melt corner.
repair under#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-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 u•el/s list all depths ifd eren!(example-3 a 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10. C,0 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfsrater level is above casing,use"+"Static water level below top of casing: (ft.) 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
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018