GW1-2022-07409_Well Construction - GW1_20220530

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTIONft. ft.
A - 4226 _
`` � fr. ft. I
NC Well Contractor Certification Numberr '15:OUTER CASING for mulfi-cased wells OR LINER if a licable)
GEOLOGIC EXPLORATION MpY 3 0 2022 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name r` ,L�
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: y„aQ1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0,0 ft. 9.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. fr.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9.0 ft. 19.0 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- 4,0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑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 EMPLACEM ENT M ETHOD
El Aquifer Test ❑Stormwater Drainage 7.0 ft- 19.0 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,soillrock type,grain size,etc.
0.0 ft' 10 ft- GRASS/TOPSOIL
4.Date Well(s)Completed: 02/1 5/22 Well ID# F2-19-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. 19.0 ft' BROWN SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
2835 HARVEY POINT ROAD HERTFORD 27944 ft. ft.
PhysicalAddress,City,and Zip ft. fr.
PERQUIMANS 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-7.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
360 05' 49.32" N 760 19' 23.08" W "'" 04/12/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify iliac the troll(+)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or C5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVe//Construction Standards and that a copy
lfthis is a repair,Jil/out known uve//construction/iJormation and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back oJ'1his Jorm.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.0 (ft.)
For multiple wells list all depths ifdii ferent(example-3 t@r 200'and 2 til100) Submit this GW-1 within 30 days of well completion per the following:
7.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
IJ'trater level is above casing,use"+"
f' Static water level below top of casing: A) 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-Loon 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018