GW1-2022-07404_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES !
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. ft.
NC Well Contractor Certification Number cp. ,.-� n
_ Eg y�� 5:OUTER CASING for multi-cased wells OR LINER if"a rlicable
GEOLOGIC EXPLORATION Z'4=.*�� 5 , ROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name MAY 3 0 2022 16.INNER CASING ORTUBING cothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,Coun(y rlq/ L°nf 4' .l?�r"a+tltC�1 fko It. 6.0 ft• 2.0 1°' SCH 40 PVC
3.Well Use(check well use): 11 ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 ft' 16.0 ft' 2.0 "' 1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt' 1.0 ft' PORTIANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL'PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft• 16.0 It. 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 ft• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 02/14/22 Well ID# SSA-MW-2 1.0 ft. 4.0 ft. BROWN CLAY
5a.Well Location: 4.0 1" 11.0 ff GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 11.0 ft. 16.0 ft. BROWN SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2835 HARVEY POINT ROAD HERTFORD 27944 ft. ft.
Physical Address,City,and Zip ft. ft.
PERQUIMANS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-1.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
360 05' 44.31" 760 19' 29.00" °
N W �� �.� _''� 04/12/22
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing[his form,I hereby cer!fy that the me//(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO I5A 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 oftnis record has been provided to the well owner.
repair under 921 remarks section or on the back oflhis 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: 16.0 (ft.)
For multiple,revs list all depths ifdii ferent(example-3 tt 200'and 2 r@i 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water tenet is obore casing,use"+•'If 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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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