GW1-2021-02759_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD GW For Internal Use Only: I
1.Well Contractor Information: .
KENNY SARGENT '��
,t 19.WATER ZONES E j
Well Contractor Name ,,. )\ FROM 'r0 I DESCRIPTION
A - 4226
NCWellContractorCertificationNumber �151itl"3
GEOLOGIC EXPLORATION �Vus 15.OUTER CASING for multi easedwclls OR LINER ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(t.e.II/C.County.State,Variance.etc.) 0.0 ft. 155.0 1- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. fr. '"•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 ft' 20.0 ft- 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri atlon 0Wells>100000 GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 9.0 ft- PORTMD 9ENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACP-IEN•rmETHOD
❑Aquifer Test ❑Stormwater Drainage 12.0 ft. 20.0 ft. 20-40 ! FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
CGeothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type, rain size,etc.
0.0 ft. 1.0 fL TOPSOIL/WOODS
4.Date Well(s)Completed: 07/14/21 Well ID# MW-16 1.0 ft. 20.0 ft. RED/BROWN SILT
5a.Well Location: ft. ft.
MGP - DUKE ENERGY ft. ft.
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
100 NORTH CENTENNIAL STREET HIGH POINT 27260 ft. ft.
Physical Address,City,and Zip ft. tt.
GUILFORD 21.REMARKS
County Parcel.Identification No.(PIN) BENTONITE SEAL-9.0-12.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat'long is sufficient) 22.Certification:
805945.58 N 1703893.09 Wj fn�l t "" 08/24/21
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
13v.signing this form.l hereby certify dial the well(.%)was(irerc)cnnsu•ucled in oce•ordance hills
7.Is this a repair to an existing well: ❑Yes or C9No 15A NCAC 02C.0100 or 15.4 NCAC 02C.0260 Well Construction Standards and dra a copy
I/this is a repair.fill out known well construction information and explain the nature of the of this record has been provided ro the well owner.
repair under ell remarks section or on the back t f this farm.
23.Site diagram or additional rs•cll details:
8.For Geoprobe/DPI'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessan
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 ft,)1•nr multiple u"el/s list all depths if «di&rent(example-3 200'and 2 100') ( Submit this GW-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 (DWR).
Ifuoterlet•el is abo•e caring,use•'+" Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
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11.Borehole diameter: 6.0 (in,) 24b. For Iniection Wells:Copy to DWR;Underground Injection Control (IIJC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to Elie
(i.e.auger,rotary,cable,direct push,ere.) County environmental health department'(of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing over II00,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.field(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