__20220311 (40)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
WellFROM TO , DESCRIPTION
Contractor Name
ft. ft.
A - 4226 ft. ft. I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS 1 MATERIAL
ft. ft. - in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft' 10.0 ft' 6.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 50.0 ft' 6.0 in' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 ft. PORTLAND'BENTONITE SLURRY
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8.0 II. 50.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0.0 It' 6.0 ft' BACKFILL/GRAY SILTY GRAVEL
4.Date Well(s)Completed: 03/07/22 Well 1D# RW-7 6.0 ft. 19.0 ft' BROWN SILTY CLAY
5a.Well Location: 19.0 ft. 28.0 ft. BROWN SILTY SANDY PWR
SEABOARD CHEMICAL 28.0 ft. 41.0 ft* GRAY SILTY PWR
Facility/Owner Name Facility ID#(if-applicable) 41.0 ft. 50.0 ft' E 1 BROWN SILTY PWR
5899 RIVERDALE DRIVE JAMESTOWN 27282 ft. ft.
ft. ft.
Physical Address,City,and Zip
GUILFORD 21.REMARKS
•
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-8.0 FEET .
MAR 1 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
35° 56' 49.67" 79° 54' 38.22"
N W16-„,„;•:-.)tir+ >
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 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 I 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: 50'0 (ft.)
For multiple wells list all depths ifdii different(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
12.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I/water level is above casing,use"+" i
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(1UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Openl-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 producingover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) _ Method of test: !
i
t
13b.Disinfection type: Amount: I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018