GW1-2022-07408_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 1a.WATER ZONES
Well Contractor Name y���ree^^^��� FROM TO DESCRIPTION
rn ,' I\ ft. ft. 1
A - 4226 0- a ft. ft. 1 1
NC Well Contractor Certification Number_ MAY 3 0 2022 `15.OUTER CASING for multi-cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name w51si'+'1 •.f�i:T
j
t'�`$ft
V.gq ojisoc-, -16.INNER CASING OR•TUBING(geothermal closed-loop)-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ff 5.0 ft. 2.0 t"' 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 S.0 ft• 15.0 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,'
❑irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTIANDBENTONITE SLURRY
Monitoring El 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 ❑Stormwater Drainage 3.0 ft• 15.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING COG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhvck e, inin size,etc.)
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 02/15/22 Well ID# FFSF-MW-2 1.0 ft. 4.0 ft. BROWN CLAY
5a.Well Location: 4.0 ft' 11.0 ft. GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 11.0 ft• 15.0 It- 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- 1.0-3.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 22.Certification:
360 05' 47.25" N 760 19' 36.26" W 04/12/22
6.Is(are)the well(s)' MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing th s 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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards-and that a copy
lflhis is a repair,fill out known well construction information and explain the nature ofthe o 1his record has been provided to the well ouner.
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 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: 15.0 (ft.)
Fbr multiple wells list all depths iif'df&renl(example-3 n 200'and 2 tt 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),
/fwnter level is above caring,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
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