GW1-2022-07414_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
P ft.
NC Well Contractor Certification Number t
'-,UEI 15.OUTER CASING for multi-cased w in.ells OR LINER if a licable
ft.
GEOLOGIC EXPLORATION ^ FROM TO DIAMETER THICKNESS MATERIAL
Company Name .
MANNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _ ;.�}v'i::: VOA FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,dhaVl,'Ylalegfwq3}F i• .J 0.0 ft' 7.0 ft 2.0 '"' 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 7.0 ft' 17.0 It. 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
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft. PORTLANDBENTONITE SLURRY
25Monitoring ❑Recovery H. ft.
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Reinediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 5.0 1` 17.0 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,soiUmck type,grain size,etc.
0.0 It. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 02/15/22 Well ID# F2-19-MW-3 1.0 ft. 4.0 ft. BROWN CLAY
Sa.Well Location: 4.0 ft. 7.0 ft. GRAY SILTY SAND
HARVEY POINT FEDERAL FACILITY 7.0 ft- 17.0 fry 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 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-2.0-5.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
360 05' 44.97" N 760 19' 28.31" W O.,,J,J� -P 04/12/22
6.Is(are)the well(s)• [EPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [ENo 15A]VCAC:02C.0100 or hA NCAC 02C.0200 Well Construction Standards and that a copy
ifthis is a repair,fill out known well construction information and explain the nature ofthe oflhis 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-i 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: 17.0 (ft.)
For multiple bells list al/depths iij'd/Brent(example-3@200'and 2@/00')10. Submit this GW-1 within 30 days of well completion per the following:
C•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if
6.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) 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 27699-161 1
13b.Disinfection type: Amount:
Fonn GW-i North Carolina Department of Envirotitnental Quality-Division of Water Resources Revised 6-6-2018