GW1-2021-02756_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1 f
KENNY SARGENT C lr"' F'' ajF l 14.WATER ZONES
Well Contractor Name
��; .�+-�a:.. FROM TO DESCRIPTION
- ft. ft. P
A - 4226 ft.
NC Well Contractor Certification Number t• 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLO RATION
FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
Lied all applicable sell consiruciion permil.c(i.e.111C.('aunt/•,Slale.Variance,etc.) 0.0 ft. 55.0 r- 2.0 in. SCH 40 PVC
3.Well Use(check well use): tr. fr. In•
17.SCREEN i
Water Supply Well:
FRONT TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft' 10.0 ft' 2.0 in. 1.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑Irri ation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&ADIOUNT
Non-Water Supply Well: 0.0 fly 1.0 fry PORTLAND8ENTONRE SLURRY
(EMonitoring ORecovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/C RAVEL PAC K(ifa licable
•Aquiter Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENTMLTIIOD
•Aquifer Test OStormwater Drainage 3.0 ft• 10.0 e• 20-40 FINE SILICA SAND
OExperimental Technology OSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,wittrock e, min sae,etc.
0.0 ft• 1.0 ft- TOPSOIL
4.Date Well(s)Completed: 07/15/21 Well ID# MW-14WT 1.0 ft• 100 ft' BROWN SILT
ft. ft.
5a.Well Location:
MGP - DUKE ENERGY rt. rt.
Facility!Owner Name Facility IDX(ifapplicable)
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONUE SEAL- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if,tvell field,one Iat/long is sufficient) 22.Certification:
805816.11 N 1703941.81 W 08/24/21
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
liv signing This Jbrin,/hereby certify that the,ire//(.t)vas(were)cnnstrucied in ace•ort/attcc milt
7.Is this a repair to an existing well: OYes or MNo 15A N('A('02('.0100 or l5A NCAC OIC.0200 Well(•orutruction.Standard,an(11h(n a copy
/J'thi.s is a repair,fill ad krtau•n yell construction iiiJortnation and explain the nature nJ'the (y this record has been prorided m the yell oirner.
repair tntrler 21 renrarkv xeclion or on the back of7ltis font.
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: 10.0 (ft.)
1•br nuilliple❑•ells list all depths gVijjerent(example-3(r 00'mrd 2n100') Submit this GVI•'-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7.5 (ft) 24a• For All Wells: Original form to Division of Water Resources (DW'R).
ry'unre,lore/is above coxing,use ' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter: 6.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC 24c.For Water Supply and Open-Lod i IT,Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push.etc.) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLI': 24d.For Water Wells producing over 100,000 GPD:
13a.field(gpm) Methodethod of test: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S
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