GW1-2022-01759_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 S FROM TO DESCRIPTION
ft. ft.
A - 4121 5 2e2, ft. ft.
NC Well Contractor Certification Number FEB 1
15.OUTER CASING for multi-cased wells OR LINER if a lieable
GEOLOGIC EXPLORATION P � FROM TO DIAM E7'ER TRICKINESS MATERIAL
1:40 d gg2n �.�i ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.IJIC,County,State,Variance,etc) 0.0 ff 22.0 fr' 2.0 1 t" SCH 40 PVC
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22.0"' 27.0 ft' 2.0 i"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. in.
❑Ind ustrial/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- 15.0 ft' PORTLAND BENTONITE _ SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20.0 ft- 30.0 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,soiVt»ck type, rain size,etc.
0.0 fr• 7.0 fr, RED CLAY
4.Date Well(s)Completed: 12/16/21 Well ID# PZ-3 7.0 e• 19.0 fr• BROWN SAND
Sa.Well Location:
19.0 fr, 29.0 ff BROWN CLAYEY SILTY SAND
CLIFFSIDE STEAM STATION 29.0 ft- 41.0 ft- PWR
Facility/Owner Name Facility ID#(ifapplicable) 41.0 ft- 45.0 fL ROCK
573 DUKE POWER ROAD MOORESBORO 28114 ft. D.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS -
County Parcel Identification No.(PIN) BENTONITE SEAL 15.0-20.0 FT&30.0-45.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 13' 09.61" N 810 45' 25.14" W /4/ A� 01/31/22
6.Is(are)the well(s): NPermanent or OTemporary Signature of Certified Well Contractor ' Date
By signing this firm,I hereby certify that the well(s)was(were)constructed in accordance wilh
7.Is this a repair to an existing well: ❑Yes or ONo I5A NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a cony
If this is a repair,Jill out known trell construction information and explain the nature of the oJ'this record has been provided to the tvell owner.
repair under 821 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 Ovet'in Remarks Box).You may also attach additional pages if necessan'.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 27.0 (ft.)
(•im multiple wells list al/depths ifd�erent(example-J a 200'and 2 tt/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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
I1.Borehole diameter: 6 0 (in,) 24b. For Infection 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018