GW1-2022-08423_Well Construction - GW1_20220427

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. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a dicable'
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 ft. 1 30.0 fi- 1 6.0 '" SCH 80 PVC
16.INNER CASING OR TUBING(geothermal closed-loo t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
l,i.rt nil applicable well c•onsvruetion permits(i.e.(11C.C'ounpa Slate,Variance.etc.) 0.0 ft' 42.0 f`' 2.0 In' SCH 40 PVC
3.Well Use(check well use): rt. fr. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER ISLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 42 0 fr• 52.0 ft' 2.0 1O' O10 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑WellS> 100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 n- 29.0 ft. PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery 0.0 ft. 30.0 ft. PORTLANDBENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a t licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Storimvater Drainage 39.0 ft. 53.0 ft. 20-40 FINE SILICA SAND
❑ENperimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heat ing/Cool ing Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhnek t•pe,gnain size,etc.
0.0 f`• 1.0 f`• GRASS/TOPSOIL
4.Date Well(s)Completed: 04/06/22 Well ID# CPA-9D 1.0 f�• 13.0 ft. BROWN SILTY CLAY
ia.\fell Location: 13.0 ft' 27.0 ft. BROWN SANDY SILT
BUCK STEAM STATION 27.0 ft. 49.0 ft. BROWN SILTY PWR
Facility/Owner Name Facility ID#(il'applienble) 49.0 ft• 53.0 n- GRAY ROCK
1555 DUKEVILLE ROAD SALISBURY 28146 ft. ft. ^ zI
Physical Address,City,laid Zip ft. ft.
ROWAN 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-29.0-39.0 FEET
..+
ib.Latitude and longitude in dcgreeshninutes/seconds or decimal degrees:
(ifwell field,one Wilong is sufficient) 22.Certification:
350 42' 43.14" N 800 22' 15.72" W �"� 04/11/22
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Br signing this form,l hereby c•ertif6 that the bell(.)was(here)con.strucled in accordance mill)
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Sundords and that a copy
l/this is a repair.fill out known well construc-tion it lbrnution and explain the nantre of the gl'lhis record has been prorided to the well owner.
repair under=21 remorkt section or on the back gf)his/firm.
23.Site Diagram or additional well details:
8.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wel Is (add'See Over'in Remarks Box).You may also attach additional pages if necessaq.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface. 52.0 (ft.)
For multiple me//t li.sl al/depths ifdiJJerent(eranlple-3@200'and 2 n 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 17.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
11*maer lere/is above casigq,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,romy,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 27699-1 61 1
13b.Disinfection type. Amount:
Form G W-I North Carolina Department of Em'iromnental Quality-Division of Water Resources Revised 6-6-2018