GW1-2022-07412_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 rt. ft.
NC Well Contractor Certification Number ,nC IN `
15.OUTER CASING for multi-cased'wells OR LINER ifa licable
GEOLOGIC EXPLORATION q q FROM TO DIAMETER THICKNESS MATERIAL
A A AV 3 4 / /.� ft. I ft. I in.
Company Name
NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable well construclion perntils(i.e.UIC,County, 'late,Varia0 i 0.0 ft- 7.0 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 7.0 ft. 17.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndLIStrial/Commercial ❑Residential Water Supply(shared) 7 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 5.0 ft. 17.0 ft. 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) FROM TO DESCRIPTION color,hardness,soiUmck type,grain sim,etc.)
0.0 ff• 1.0 ft• GRASSjfOPSOIL
4.Date Well(s)Completed: 02/1 S/22 Well ID# AR-MLA-2 1.0 fr. 4.0 ft. BROWN CLAY
Ia.Well Location: 4.0 ft. 12.0 ft' GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 12.0 ft• 17.0 ft. BROWN SAND
Facility/OwnerNatne 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) BENTONIfE SEAL-2.0-5.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
360 05' 44.53" N 760 19' 28.18" W �T' 04/12/22
6.Is(are)the well(s): TPermanent or ❑Temporary Signature ofCertitied Well Contractor Date
By signing this form,/hereby certify that the irell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or i5A NCAC 02C.0200 We//Construction Standards and that a copy
/fihis is a repair,fill out known well construction information and explain the nature of the ofilds record has been provided to the well owner.
repair under 921 rentarks 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: 17.0 (ft.)
For intdtiple we//s list all depths i/'diereni(arannple-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
$.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/jwater level it above casing,use"+"
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,i611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018