GW1-2022-08425_Well Construction - GW1_20220427

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.
A - 4226 ft.
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casednvells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAD1 ETER THICKN FSS MATERIAL
Company Name 0.0 ft 55.0 ft. 6.0 i"• SCH 80 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well c•onstrucHou pernnits(i.e.UIC.C ountr,State, Variance,etc.) 0.0 ft 115.0 ft. 2.0 "' SCH 40 PVC
3.Well Use(check well use): tt. e. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 115.0 ft• 125.0 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 TO MATERIAL EMPLACEMENTMETIIOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 52.0 ft' PORTLANDBENTONITE SLURRY
OflMonitoring ❑Recovery 0.0 ft- 55.0 ft. PORTLANDBENTONITE SLURRY
Injection Well:
ft. ft.
❑Aquiter Recharge 0GrOL1nd\eater Remediation
19.SAND/GRAVEL PACK(ifa r nlicable)
❑Aquiter Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENPLACEMENTMETHOD
❑Aquifer Test ❑Storinxvater Drainage 111.0 ft. 125.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 04/06/22 Well ID# CPA-9BR 1.0 ft• 13.0 ft• BROWN SILTY CLAY
ia.Well Location: 13.0 ft. 27.0 1t' BROWN SANDY SILT
BUCK STEAM STATION 27.0 ft 48.0 ft• BROWN SILTY PWR
FacilitylOwner Name Facility ID4(ifapplicable) 48.0 ft• 125.0 ft. GRAY ROCK
1555 DUKEVILLE ROAD SALISBURY 28146 rt. ft.
Physical Address,City.and Zip ft. ft. !^°•�
gym. A
ROWAN 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL-52 1 V4EET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***U-PACK SCREEN** 027
(ifwell field,one lit/long is sufficient) C'ar:-�i r•,
22.Certification: , �;.,�,c sa•.;�r
350 42' 43.14" N 800 22' 15.72" " � %�a r`10L��i�'2
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
ByskvninS this•Jbrm,1 hereby certlfj•that the ire//(s)iras(were)c•omsn•ticted in accordance iritb
7.Is this a repair to an existing well: ❑Yes or nNo ISA NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a caw
l f this is a repair,(ill out known ire/l construction h formation and explain the nature r f the afthis record has been prortdecl to the ire//owner.
repair sunder 1:21 remarkr.sec•tion or our the back aJ)his Jbrm.
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 into
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofvvells (add'See Ovet in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 125. (ft.) Submit this GW-I within 30 days of well completion per the following:
l•br n,ntniple u•e/tx list all depthsiJ'diJJerent(ernunple-9 u 200'nml 2 a l00') y p p g'
17.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
I/\rater ferel is nbnre 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,rouny,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(-pin) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Forni GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018