GW1-2022-08648_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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BRIAN THOMAS 14.WATER ZONES E ,.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 t
NC Well Contractor Certification Number ft. ft.15.OUTER CASING formulfr-easel wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft. 110.0 ft- 1 6.0 I i i" SCH 80 PVC
Company Name
I6.1NNER CASING OR TUBING• eothermal closed-loop)"
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Slate,I�ariance,etc.) 0.0 ft- 136.0 ft- 2.0 t"' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 136.0 a' 146.0 ft' 2.0 m, .010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 107.0 ft- AQUAGUARD SLURRY
[EMonitoring ❑Recovery 0.0 ft' 110.0 ft' PORTIANOBENTONITE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1132.5 ft• 146.0 ft• 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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- 1.0 ft- GRASS/TOPSOIL
4.Date Well(s)Completed: 04/27/22 Wel11D# CCR-7BR 1.0 ft. 54.0 ft- BROWN SILTY CLAY
5a.Well Location: 54.0 ft' 79.0 ft' BROWN SANDY SILT
CLIFFSIDE STEAM STATION 79.0 ft- 102.0 ft• BROWN SILTY PWR
Facility/Owner Name Facility lD#(ifapplicable) 102.0 ft- 146.0 ft• WHITE/GRAY ROCK
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip ft. fL
RUTH ERFORD 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 107.0-132.5 FEET
***;U-PACK***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 12' 51.07" N 81° 45' 12.13" W t, ,..--
05/03/22
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature ofCeni6ed Well Contractor Date
By signing this form,1 hereby certify that the well(. v u+�Y�o in lNxir an a irh
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 01C.0100 or 15A NCAC 01C.0100 I a cap}
If ihi.s is a repair,fill out known well construction itrfbrmalion and explain the nature nJ'rhe ofdris record has been provided to the well owner. "
repair under,'11 remarks section or on the hack of this form. MAY 1 4 2022
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may i 91WAary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9-Total well depth below land surface: 146.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
Far nurlriple wells list all depthsijd�erent(example-3 ae100'and.n 100')
50.0 24a. For All Wells: Original forrn to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
/J'u�uter level is above c•using,use"1"
11.Borehole diameter: 6.0/10.0 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
SONIC/HQ CORE Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh;NC 27699-1611
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13b.Disinfection type: Amount: f
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.2018
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