GW1-2022-03273_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: l
KENNY SARGENT 14.WATER ZONES }
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TO DESCRIPTION
Well Contractor Name ft.
A - 4226
a.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ff 2.0 fL 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN.
Water Supply Well:
FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.0 ft' 8.0 fL 2.0 i" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifapplic able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1.5 ft. 8.0 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,sail/rock e, �min size,etc.
0.0 ft. 1.0 ft. GRASSJTOPSOIL
4.Date Well(s)Completed: 02/1 1/22 Well ID# MW-14 1.0 ft. 3.0 ft' BROWN SILTY SAND
5a.Well Location: 3.0 ft' 8.0 ft' GRAY ROCK
BROWNFIELD ASSESSMENTS ft. fr.
Facility/Owner Name Facility ID#(ifapplicable) tt. ft.
175 SOUTH WADESBORO BLVD MT GILEAD 27306 rt. ft. MAR 14
Physical Address,City,and Zip ft. ft.
MONTGOM ERY 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 06.06" N 800 00' 23.12" W 03/01/22
6.ls(are)the well(s)' (Permanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the evell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,.ill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdtfferent(example-3@200'and 2@100')
2.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I(waier level is above casing,use
24b. For Injection Wells:Copy to'DWR, Underground Injection Control (IUC)
11.Borehole diameter: 6.0 (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depa I rtment of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(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