GW1-2021-03379_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Michael Hansen 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4381 A ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a Gcable
Cascade Drilling FROM TO 11 rTHICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:NA FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 62 ft- 2 1 . 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 13Municipal/Pubhc 62 ft. 67 ft 2 .02, sch 40 PVC
IN
eothermal(Heating/Cooling Supply) Residential Water Supply(single)
ndustrial/Commercial Residential Water Supply(shared) 18.GROUT
rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 ft3 ft• Concrete oured
Monitoring Recovery 3 ft- 54 fL Neat Cement tremie pumped
ection Well: 54 • 60 ft• 3/8 chips raviquifer Recharge Groundwater Remediation
19.SAND/GRAVELTACKc if a' livable quifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test E)Stormwater Drainage 60 ft• 67 ft• #2 sand gravity
xperimental Technology Subsidence Controleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaeothermal eating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock in s' etc.
0 ft• 1.5 ft- Fill, brown sand
4.Date Well(s)Completed.4/23/2021 well ID# 1.5 ft. 61.5 ft ASh'
5a.Well Location: 61.5 ft. 62 ft. Brown sand with silt
Duke Energy DMM4 62 ft- 64.5 ft. Sapprolite
Facility/Owner Name Facility ID#(if applicable) 64.5 ft' 67 ft• Weathered bedrock
1700 Dunnaway Rd, Semora, NC. 27343
Physical Address,City,and Zip
Person 21•REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :n rocessin(J. Unit
(if well field,one lab long is sufficient) 22.Certification: ; UV R sermon
36.476682 N 79.065884 W Ii
5/13/2021
6.Is(are)the well(s)OPermanent or E3Temporary Signature o Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 67 (ft)
P 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdifferent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: 17 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Sonic above, also submit one copy of this form;within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Suaoly&Iniecition Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction''toithe county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016