GW1-2022-01758_Well Construction - GW1_20220215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4121 RECEIVED ft.ft t.
. f ft.
NC Well Contractor Certification Number L_�(n� 15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION 1 EB ���� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name Uve
' p
n�gltiw'_r,��vim'_{ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) 0.0 ft- 25.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft' 30.0 it- 2.0 in. .010 SCH 40 PVC
❑Geothermal(Hcating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. Iin.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 17.0 ft- PORTLAN0 BENTONITE SLURRY
(Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 22.0 ft• 33.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/nick type, ,Ain sin,etc.
0.0 fr 8.0 ff RED SILTY CLAY
4.Date Well(s)Completed: 12/1 5/21 Well ID# PZ-2 8.0 it• 19.0 ft' BROWN SAND
5a.Well Location: 19.0 ir' 29.0 ft' BROWN SANDY SILT
CLIFFSIDE STEAM STATION 29.0 ft 36.0 ft- PWR
Facility/Owner Name Facility ID#(if applicable) 36.0 it• 39.0 it• ROCK
573 DUKE POWER ROAD MOORESBORO 28114 rt. ft.
Physical Address,City,and Zip
fr. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 17.0-22.0 FT&33.0-39.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
350 13' 10.68" N 81° 45' 28.01" W 01/31/22
6.Is(are)the well(s)' INIPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify thai the wells)was(were)constructed in accordance wiuh
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a cope
If This is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the quell 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 1 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: 30.0 (ft.)
par multiple wells list al/depths ii"di fereni(example-3@200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
f'u�ater level is shove casing,use"+i Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f "
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 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
t
13b.Disinfection type: Amount:
II
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018