GW1-2022-01761_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 CEI FROM TO DESCRIPTION
ft. ft.
A - 4121
NC Well Contractor Certification Number F t a v 15 20
2? it. ft. i
��������,�,,yy.���1' 15..OUTER CASING for-multi-cased wells OR.LINER if a tlicI
GEOLOGIC EXPLORATION lrlf Pf�''e Unh FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. in.
Company Name
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.UIC,County,State,Variance,etc) 0.0 ft. 22.0 ft. 2.01 n. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22.0 H. 27.0 ft. 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 15.0 ft' PORTLAND BENTONRE ,_SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20.0 ft' 30.0 rt' 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,soil/rock type,grain size,etc.
0.0 ft. 0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 12/16/21 Well ID# PZ-5 7.0 'ft. 29.0 ft. BROWN CLAYEY SILTY SAND
5a.Well Location: 29.0 ft. '39.0 ft. BROWN SILTY SAND
CLIFFSIDE STEAM STATION 39.0 ft. 43.0 ft. PWR
Facility/Owner Name Facility ID#(ifapplicable) 43.0 ft. 49.0 ft. ROCK
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 15.0-20.0 FT&30.0-49.0 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 07.04" N 810 45' 20.62" W /4//'Alp 01/31/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor : Date
By signink this fornt.J herebe cerltfv that.lhe ¢el/(s)mas_(vere)constructed in accordance.with -
7.Is this a repair to an existing well: ❑Yes or I19No 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and ilia/a copy
//'this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the we//owner.
repair under 921 remarks.section or on the back g1'1his 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: 27.0 (ft.)
For multiple we/h list al/depths ifdii ferent(example-3 r@r 200'and 2@100') 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, 1617 MSC,Raleigh,NC 27699-1617
lJ'water level is above casing,use
11.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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018