GW1-2022-07405_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4226 ft. ft.
q ft. ft.
NC Well Contractor Certification Number
R� � 5 9 9oA�
Z. EU 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
� ft. ft. in.
Company Name M Nil
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: g Unh FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable hell construction permits(i.e.U/ ,County,stJa9., jv (catc.J 0.0 ft. 6.0 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 6.0 fr. 16.0 ft' 2.0 m' .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 TO MATERIAL EMPLACEMENT METHOD B AMOUNT-
Non-Water Supply Well: 0.0 ft' 1.0 ft' PORTfANDBENTONITE SLURRY
(EMonitoring ❑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 ❑StormwaterDrainage 4.0 ft. 16.0 ft. 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control fr. 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 e, nin size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 02/15/22 Well ID# FFTA-MW-3 1.0 ft. 4.0 ft. BROWN CLAY
5a.Well Location: 4.0 et. 10.0 ft. GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 10.0 ft. 16.0 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. I ft.
PERQUIMANS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
360 05' 43.31" N 760 19' 28.59" W - 04/12/22
6.Is(are)the well(s): IflPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this forut,I hereby certify ilia'the nrell(s)was(here)constructed in accordance u,iih
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standardv and that a copy
li"this is a repair,fill out known we//construction information and explain the nature of the ofltis record has been provided to the well owner.
repair under 921 reinarkr section or on the back ofihis./brin.
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: 16.0 (ft.)
For multiple wells list all depths ifdierent(example-3 rt 200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
6•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:/flraier level is abo•e casing,use"+" (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