GW1-2022-07410_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
ft. ft.
A - 4226 �;�� ��� ••� ft. D. �
NC Well Contractor Certification Numbere, 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION e�AY 3 0 2022 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name _ /. Unn
(,.'✓�'" 16.INNER CASING OR TUBING(geothermal closed-loov
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(1.e.UI ,County,Stdre;l/ariance,etc.) 0.0 It. 9.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.0 ft. 19.0 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 00 ft- 40 ft- PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑ 19.SAND/GRAVEL PACK if alivableAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 7.0 ft. 19.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control rt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,soilhnck type,grain sim,etc.
0.0 ft. 1.0 ft- GRASS/TOPSOIL
4.Date Well(s)Completed: 02/15/22 Well ID# F2-19-MW-1 1.0 ft. 4.0 ft. BROWN CLAY
5a.Well Location: 4.0 ft' 10.0 ft' GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 10.0 ft• 19.0 ft• BROWN SAND
Facility/Owner Name Facility ID#(ifapplicable)
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) BENTONITE SEAL-4.0-7.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 05' 48.98" N 760 19' 25.56" W 04/12/22
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
lflhis is a repair,fill out known well construction information and explain the nature ofihe ofthis record has been provided to the well owner.
repair under 921 remarks section or atn the back ofthis 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 ofwells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.0 (ft.)
!•or nmhiple wel/s list al/depths ifdiJJerent(example-3 rr 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: 7.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
/f water 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-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
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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