GW1-2022-05125_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT f4:WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
°'
A - 4226 ft, ft.
�;,.,-..� ������ ,' ft. ft.
�-.,
NC Well Contractor Certification Number -15r OUTER CASING for multi-cased`wells OR LINER'if a licable
GEOLOGIC EXPLORATION MAY 3 1 2Q22 FROM TO DIAMETER TTIICKNESS MATERIAL
ft, ft. in.
Company Name i., 1J1417
_ 3 16.INNER CASING OR TUBING eorhermal closed-Ioo
2.Well Construction Permit#: IflfiO'"" r1 '?kOLl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 4.0 ft. 2.0 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 ❑MunicipaUPublic 4.0 f" 14.0 ft 2.0 'n' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18."GROUT '
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 2.0 ft. PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery 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 ❑StormwaterDrainage 3.0 ft- 14.0 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,soittrock typN gmin size,etc
0.0 ft. 1.0 ft- CONCRETE/GRAVEL
4.Date Well(s)Completed: 04/25/22 Well ID# MW-1 1.0 ft. 12.0 ft- BROWN SANDY CLAY
5a.Well Location: 12.0 ft. 14.0 ft' BROWN SILTY SAND
SPEEDWAY- 8244 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
124 NC HIGHWAY 55 MOUNT OLIVE 28365 ft. ft.
Physical Address,City,and Zip
ft. ft.
WAYN E 21:REMARKS 1%
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 41.85" N 780 03' 48.66" W 04/29/22
6.Is(are)the well(s): (Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.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 ofthis record has beenprovided to the well owner.
repair under#21 remarks section or on Cite back ofthis 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: 14.0 (ft.
For multiple wells list all depths ifdii ferent(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: 7.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter•• 6.0 (in) 24b.For Injection Wells:Copy to DWR,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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018