GW1-2021-02754_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
20A�Well Contractor Name �� �� '� ` FROM ft. TO DESCRIPTION
A - 4226 S�
r��fl;;`>;iiJ tiJYll) ft. ft. �.
NC Well Contractor Certification Number 1_F 4'r(111 t
ablel
GEOLOGIC EXPLORATION 1tiSult„ ®�u J�snOD FRO 1 15. TER CASING form DIAM ETEReIIs OTH CKNESS a InMATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft. 5.0 ft- 2.0 "' I SCH 40 PVC
3.Well Use(check well use): R. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft 10.0 rt' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑We]Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt• 1.0 ft- PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 rt• 10.0 ra 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 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/imck type,gimin size,etc.
0.0 ft. 1.0 rr• TOPSOIL
4.Date Well(s)Completed: 07/14/21 Well ID# TMW2-25 1.0 ft• 10.0 rt• BROWN SILT
5a.Well Location:
MGP - DUKE ENERGY
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260 ft. ft.
Physical Address,City,and Zip
ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
805816.11 N 1703941.81 W #jtv1� 08/24/21
6.Is(are)the well(s): ❑Permanent or INTemporary Signature of Certified Well Contractor Date
by signing thisJarm,/hereby cerrify that the we/l(s)u•as(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes Or [!5No hA NCAC 02C.0100 or 15A NCAC 01C..0200 Well Construction Sandards and that a c•opr
lf'ihis is a repair,fill out known well consiruc•tion inJort ation and explain the nature of the of this record has been provided to the well owner.
repair under'•'21 remarks section or on the back gfthis fin-in.
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You'may also attach additional pages ifnecessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10.0 (ft.)
For multiple ire/Ls list all depths iJ'dyJerent(example-3@200'and 1@100') Submit this GW-I within 30 days of well completion per the following:
10. 7.5 24a. For All Wells: Original form to Division of Water Resources (DWR),
i rater level is above casing,use Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1Jl "+"
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh;NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6-6-2018