GW1-2021-00007_Well Construction - GW1_20210211

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WELL CONSTRUCTION RECORD
NORTH CAROLINA
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• Construction Electronic
North • Department of • - Quality
Divisionof • •
September2020
CONTACT INFORMATION
......................................................................................................................................................................................................................................................................................................................................................................................
Contact Name* Phillip Banks
Email Address* [e-mail]
This will be used to email you a copyof the submitted form.
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
C Owner c: Well Contractor
1.Well Contractor Information:
...................................................
Well Contractor Name NC Well Contractor Certification# Company Name
Nicholas Moreno
2.Well Construction Permit#:
..............................
NIA
List all applicable well construction permits(i.e.fVbnitoring Wells,UIC,County,CCPCUPq etc.)
What type of well is this?* C Injection Well Non-Water Supply Well
C Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
1/18/2021 2 gpm
(gallons per minute)"
5.Well Location
Facility/Owner Name* Duke Energy Progress/Rogers Energy Complex
Facility ID# (If applicable)

County* Parcel Identification No. (PIN)
Iredell
Physical Address* Street Address
1573 Duke Power Road
Address Line 2
City State/Pro\Ance/Region
Mooresboro NC
Postal/Zip Code Country
28114 US
Latitude* Longitude
35.217587 -81.752665
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)Plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.)
40
For multiple wells list all depths if different(example-3 200'and 2@100')
9a.What is the depth of the casing from ground
surface?
40
in feet
10.Static water level below top of casing:(ft.)
31
If water le\,el is abo\te casing,use'Y'
11. Borehole diameter: 8
in inches
12.Well construction method:
r Auger C Air Rotary
f Cable Tool C Direct Push
f Mud Rotary C Rotosonic
r Other
14.WATER BEARING/FRACTURE ZONES
From To Description
20 40
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)

To From Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
10 40 4 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0 2 3/8"Bentonite Chips Gravity
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
8 40 20/30 Sand Tremmie
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0 20 Brown Clay
in feet in feet
20 28 Grey Ash
in feet in feet
28 40 Lenses of Ash and Brown Clay
in feet in feet
40 40 Rock
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
*Pr By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification
Signature of Certified Well Contractor
Submittal Date 2/11/2021