GW1-2021-02751_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name p FROM TO DESCRIPTION
S C r 1\ - ft. ft.
A - 4226 ;,';(I0 i_1I1I1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft,
ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 rr' 12.0 ft. 2.0 ' in. SCH 40 PVC
3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well:
PPY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 ft' 17.0 rt 2.0 "' O10 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL g• in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 6.0 fr' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well: ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 10.0 rt 17.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I 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,soiUirock e,gmin size,etc.
0.0 iL 1.0 rt' GRAVEL
4.Date Well(s)Completed: 07/1 2/21 Well ID# MW-13 1.0 rr. 170 tL BROWN SILT
ft. a.
5a.Well Location:
MGP - DUKE ENERGY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260 tr. ft.
Physical Address,City,and Zip ft. ft.
GUILFORD 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 6.0-10.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
805793.90 N 1703905.09 W �' 08/24/21
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(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standardv and that a copy
1f this is a repair,fill out known well construcrion information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks 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
For multiple wells list all depths ifdifferent(example-3 a 00'and 1@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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use-
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy toFDWR,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 Iver 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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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