GW1-2021-02750_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES I !
Well Contractor Name FROM TO DESCRIPTION
•r s L1 tt. ft. i
A - 4226 S " �t{y�
F lrl'C{MC 2,tig'Jn1l ft. ft.
NC Well Contractor Certification Number r�`VI,-31.1 ,(}t 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION VV�!�� JJtlo FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ' in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc) 0.0 ft- 25.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 fL 30.0 ft' 2.0 1° .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 19.0 ft- PORTLANDBENTONru SLURRY
IBMonitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM PLACEM ENT M ETH OD
❑Aquifer Test ❑Stormwater Drainage 22.0 ft- 30.0 ft' 20-40' FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control tr. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gamin size,etc.
0.0 ft. 1.0 ft- GRAVEL
4.Date Well(s)Completed: 07/1 2/21 Well ID# MW-13D 1.0 tr. 19.0 ft. BROWN SILT
5a.Well Location: 19.0 ft' 32.0 ft• BROWN SILTY PWR
MGP - DUKE ENERGY 32.0 fit- 39.0 ft- BROWN ROCK
Facility/Owner Name Facility ID8(ifapplicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip ft' ft'
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 19.0 22.0 FEET&30.0-37.5 FEET
;-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: COLLAPSE 37.5-39.0 FEET
(ifwell field,one lat/long is sufficient) 22.Certification:
805791.94 N 1703899.40 W �'r 08/24/21
6.Is(are)the well(s): OPermanent or OTemporary Signature ofCertified Well Contractor Date
By signing this form,/hereby certify that the wel(s)teas(here)constructed in accordance frith
7.Is this a repair to an existing well: Oyes or MNo I5A NCAC 02C.0100 or I5A NCAC 02C,0200 Well Construction Standards and that a copy
lf'this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the trell owner.
repair under s11 remarks section or on the back of this farm. i
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-I 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: 30.0 (ft.)
Fier multiple wells list all depths ifdijjerent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
7.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
/j
ft ater level is above casing,use Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
MI SC,"+"
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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oI er 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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