GW1-2022-07411_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
KENNY SARGENT 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4226 8p y�C.s�^�"
'.� b •¢ E
NC Well Contractor Certification Number "� ,,,9 d 15.OUTER CASING for multi-cased wells OR LINER if a licable'Z 1+..
GEOLOGIC EXPLORATION (n� FROM TO DIAMETER THICKNESS MATERIAL
"n y/ Q 222 ft. ft. in.
Company Name ��
2.Well Construction Permit#: 1 f Uf10 16.FROMNER CTSOING OR TU DIAMETERING her I l closed-looli)
THICKNESS MATERIAL
4 a
List all applicable well construction pernd[s(i.e.ULC. nay,StaM1f",�]!6 0.0 ft- 6.0 ft. 2•0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6.0 eL 16.0 ft. 2.0 'n• .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wel IS>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 1.0 ft. PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 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,soilkock type,gnin size,etc.
0.0 ft• 1.0 ft• ASPHALT/GRAVEL
4.Dare Well(s)Completed: 02/16/22 well ID# F5-10-MW-1 1.0 ft. 4.0 ft. BROWN CLAY
5a.Well Location: 4.0 ft• 10.0 ft- GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 10.0 ft- 16.0 ft. BROWN SAND
Facility/Owner Name Facility ID#(if applicable)
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 hit/long is sufficient) 22.Certification:
360 05' 46.15" 760 19' 37.54"
N W X14, �--'� 04/12/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the wells)was(were)cons trucled in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or LSA NCAC 02C.0200 Well Construction SiandarrA and that a copy
lf'this is a repair,Jill out known we//construction infbrmatioh and explain the nature ofthe ofilds recordhas beenprovided to the well owner.
repair under#21 remarks section or on the back oJ'this forin.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the salve 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.)
l,or undliple wells list all dept s lfdiiferenl(example-3@200'and 2@/00') 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),
lf'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 DVvR,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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018