GW1-2022-07407_Well Construction - GW1_20220530

- I �
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rr. fr.
A - 4226
ft. fr.
NC Well Contractor Certification Number r
45.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION ,�, fi FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i in.
Company Name MAY 3 0 2022
Iv1 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#' FROM TO I DIAMETER' FTHICKNESS MATERIAL
List all applicable well construction permits f.e.UIC.T i1JOr R, �,94(0i%it'1a 4T' P 0.0 ft. 7.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use):
17O' , rjhvtd?h.Ul '+ ft. fr.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.0 tt. 17.0 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 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2.0 ft' PORTLANDBENTONITE SLURRY
I!flMonitoring ❑Recovery ft. fr.
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PAC K ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 5.0 ft- 17.0 ff- 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) I
FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc.
0.0 rr. 10 fr. GRASS/TOPSOIL
4.Date Well(s)Completed: 02/14/22 Well ID# FFTA-MLA-1 1.0 ft. 6.0 It. BROWN SILTY CLAY
5a.Well Location: 6.0 fL 17.0 ft- GRAY 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.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL•-2.0-5.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
360 05' 44.20" N 760 19' 28.59" W iJ � 04/12/22
6.ls(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby ceriyJ that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
/fthis is a repair,Jill out known well construciion information and explain the nature oJ7he oJ'this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthir forin.
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: 17.0 (ft.)
For multiple wells list all depdns ifdifferem(example-3 a 200'and 2 a l00') 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),
If,rater level is above casing,use"+„ 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-Loon 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:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018