GW1-2021-02765_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT I �?; k,.J
�a'•v'• 14.WATER ZONES i
Well Contractor Name 20�1 FROM TO DESCRIPTION
A - 4226 Sc' � ` L ft. ft.
ft. rt.
NC Well Contractor Certification Number a:.,--rlrr+{;f,? '�tt J)ZI
'• 1„3's i 15.OUTER CASING for multi cased N•ells OR LINER ifa livable
GEOLOGIC EXPLO RATI�h�J' UVV OI1 FRONT TO DIAMETER THICKNESS MATERIAL
ft. ft. :in.
Company Name
16.INNER CASING OR TUBING eolhermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(1/C,Caunt)•,Slate,Variance,etc.) 0.0 fl. 6.0 ft. 2•0 in. SCH 40 PVC
3.Well Use(check well use): tr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 ft- 11.0 ft. 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heat ing/Cool i rig Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri.-ation ❑Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTLANDaENTONITE SLURRY
MMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 11 MPLACEMENTMETIIOD
❑Aquifer Test ❑Stonmvater Drainage 3.0 ft. 11.0 ft. 20-40 ! FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑'Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain sin,etc.)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks)
0.0 ft• 1.0 ft. TOPSOIL/WOODS
4.Date Well(s)Completed: 07/13/21 Well ID# MW-15WT 1 0 ft 11.0 ft. BROWN SILT
Sa.Well Location: ft. ft.
MGP - DUKE ENERGY ft. ft.
Facility/Owner Name ft. ft.
Facility IDY.(if applicable)
100 NORTH CENTENNIAL STREET HIGH POINT 27260 ft. ft.
Physical Address.City,and Zip
GUILFORD 21.REMARKS
Canty 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 lal/long is sufficient) 22.Certification:
805954.59 N 1703816.14 W „jfg' 08/24/21
6.Is(arc)the well(s)• 29Permanent or ❑Temporary Signature of Certified 117ell Contractor Date
Hv signing this fenny./hereby certify that the,reell(s)troy(it-ere)c•nnstructed in accordance n•ith
7.Is this a repair to an existing well: ❑1'es or ONo lSA NC.4C 02!'.01011 or l3A N<'A('02('.1)200 Nell('oncirucvinn Sltindartic mul that a copy
!f'Ihis is a repair,fill out knmrn well construction infnrnuation and explain the nature nl7he n/'this record hat been provided to the well ou ner.
repair utuler=21 rentarkr seciinn nr on the hock cJ'ihis fnrtn.
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 LNSTRUCTIONS
9.Total well depth below land surface: 11.0 (ft)
bar nrdtiple ire/it list al/depths ifdiQerem(esmnple-3C200'and?n loo j Submit this GW-I 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 firm to Division of Water Resources (DWR),
If later let e/is above casing.use- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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6.0 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program. 1636 MSC,Raleigh,NC 27699-,1636
12.Well construction method: SONIC 24c.For Water Su I and O en-Loa Geothermal Return Wells:Co to the
(i.e.auger,rotary.cable,direct push.etc.) county environmental heap departmeri10 jt the county where installed Copy
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:
Form GW-I North Carolina Department of Environmental Quality•Division of Water Resources I Revised 6-6-2018