GW1-2021-02758_Well Construction - GW1_20210901

i
I
i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT
14.WATER ZONES l l
.. �,-. =-�` •7 r.. FROM TO DESCRIPTION
Well Contractor Name h ft.
A - 4226 S` /,, � 2021 rt. tt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased OR LINER if a licable
GEOLOGIC EXPLORATION ,.,, I(lC -I I11I FROM TO DIAMETERi THICKNESS MATERIAL
t�t,,.-,,,a~~i^;tit, "�� J
C ft. ft. i in.
Company Name D'clta. � .,01�
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 21.0 ft. 2.0 in. $CH 40 PVC
3.Well Use(check well use): H. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 21.0 fr' 26.0 tt' 2.0 tn• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 16.0 fr• PORTLANDaENTONnE SLURRY
Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 19.0 ft 26.0 e• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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,soil/mck type,gnin sim,etc.
0.0 it 1.0 rL GRAVEL
4.Date Wells)Completed: 07/13/21 Well ID# TMW2-2D 1.0 ft. 90 ft. BROWN SILTY SAND
5a.Well Location: 9.0 if 19.0 ft' BROWN SILT
MGP - DUKE ENERGY 19.0 fr 26.0 rt' PWR
Facility/Owner Name Facility ID#(ifapplicable) 26.0 ft. 27.0 ft GRAY ROCK
100 NORTH CENTENNIAL STREET HIGH POINT 27260
Physical Address,City,and Zip ft. ft.
GUILFORD 21.REMARKS 1
County Parcel Identification No.(PIN) BENTONITE SEAL- 16.0-19.0 FEET&26.0-27.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
805816.11 N 1703941.81 N 08/24/21
6.Is(are)the well(s)• ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IDNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f 1his•is a repair,fill not known well construction information and explain the nature of the of this record has been provided to the we//'miner.
repair under r21 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 1 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: 26.0 (ft.)
For multiple wells list all depths ifdiifereni(example-3@200'and 1@100') Submit this GW-I within 30 days of swell 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 (DWR),
If waver level is above casing,use"-" Information Processing Unit,1617 MSC,iRaleigh,NC 27699-1617
L
11.Borehole diameter: 6•0 (in.) 24b. For Infection Wells: Copy to Do,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 over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC!i27699-161 I
13a.Yield(gpm) Method of test: C
13b.Disinfection type: Amount: I�
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018