GW1-2022-07406_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226
NC Well Contractor Certification Number V 15.OUTER CASING for multi-cased)wells OR LINER if a licable
GEOLOGIC EXPLORATION �AY iJ ® ��r)� FROM TO DIAMETER, THICKNESS MATERIAL
dill 3 6 ft. ft. in.
Company Name
4, m 16.INNER CASING OR TUBING(geothermal closed-loo I
2.Well Construction Permit# If1�fFfra Unh FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,=, ,etc.) 0.0 fL 6.0 ft' 2.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 ft' 16.0 ft. 2.0 in- .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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 1.0 ft' PORTIANDBENTONRE SLURRY
I!JMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT RIETHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft. 16.0 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/mck type,gnin size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 02/16/22 WeII ID# FFTA-MW-2 1.0 ft• 4.0 rt• BROWN CLAY
5%Well Location: 4.0 ft. 11.0 tt. 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' 43.20" 760 19' 28.73"
N W ��1�:�• '" 04/12/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Curti fled Well Contractor Date
By signing this form,/hereby certify that the well(s)was(here)consiructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ITNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f 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#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-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 inultiple irells fist all depths ifdiiJJerent(example-3 a 200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
6•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water)chef is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f
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:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018