GW1-2022-04411_Well Construction - GW1_20220427

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. rt.
NC Well Connector Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS DATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING Necithermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trell comstn•tic•tian permits(i.e.UIC,County,Score,Variance,etc.) 0.0 ft. 10.0 rt. 6.0 in. .188 STAINLESS STEEL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft. 40.0 ft' 6.0 in. .010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 1.0 ft. AQUA GUARD SLURRY
❑Monitoring ❑Recovery tt. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge 1513roundwater Remediation
19.SAND/GRAVEL PACK if a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑AquiterTest ❑StonnwaterDrainage 6.0 rL 41.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control rt. rt.
❑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 sim.etc.)
0.0 ft• 5.0 ft- RED CLAY
4.Date Well(s)Completed: 02/01/22 Well ID# EX-AS-5 5.0 ft. 9.0 rr. PWR
ia.Well Location: 9.0 ft. 12 0 Ic QUARTZ
CLIFFSIDE STEAM STATION 12.0 ft• 20.0 fI PWR
Facility/Owner Name Facility ID#(ifapplicable) 20.0 ff 41.0 ft. ;� r gq f
573 DUKE POWER ROAD MOORESBORO 28114
Physical.Address.City,and Zip ft. ft. 2
RUTHERFORD 21.REMARKS
BENTONITE SEAL•- 1.0-,6.Q,FE�1/5�7^^'"nn� Qp�fM 0 FEET
County Parcel Identification No.(PIN) i58
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
350 12' 52.68" N 810 45' 14.12" W
14611�� 03/23/22
6.Is(are)the well(s)• MPermanent or ❑Temporary Signature of Certified Well Contractor Date
HP signing tha f<trnn,I hereby certify that the vell(i)u•as(mere)constructed in accordance it;dt
7.Is this a repair to an existing well: Oyes or MNo 15A NCAC 02C.0100 or 15.4 A'CAC 02C.0200 16e//Construction Standards and that a copy
I1'lhis is a repair,fill(Jill known ire//construction infimaatiom and explain the nature of the ofthis record has been prorided to the ire#owner.
repair Lander '21 remarks section or an the back q/ihis fora.
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 I GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41.0 (ft.)
Par tadtip/e we//s nit an depdis ifrrifferem(eronnple-3 a inn•and 2@100•)10. Submit this GW-I within 30 days of well completion per the following:
13.52 24a. For All Wells: Original form to Division of Water Resources (DWR),
Static hater level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lf/'irnlur lere•l is abase casing.use•.,�•.
11.Borehole diameter: 16.0/6.0 (in) 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 276 99-1 636
12.Well construction method: SONIC/AUGER/AIR
24c.For Water Supply and Open-Loon 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(gym) Method of test: Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environniental Quality-Division of Water Resources Revised 6-6-2018