GW1-2022-08653_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
C
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES €
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased wells OIL if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.0 II• 1 45.0 ft- 6.0 li in. SCH 80 PVC
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.UIC,County,State,Variance,etc) 0.0 II• 55.0 ft. 2.0 "' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I-THI-Clids;ESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
55.0 65.0 2.0 .010 SCH 40 PVC*
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 40.0 It. AQUAGUARD SLURRY
(EMonitoring ORecovery 0.0 ft. 45.0 ft' PORTLANDBENTONITE 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 EMPLACEMENTMETHOD
OAquiter Test ❑Stormwater Drainage 52.0 Ir• 67.0 It• 20-46 FINE SILICA SAND
OExperimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach Additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soivrock e, rain sin,etc.
0.0 It. 2.0 ft. GRASS/GRAVEL
4.Date Well(s)Completed: 04/22/22 Well ID# CCR-U5-1 ODA 2.0 It- 13.0 fr• BROWN SILT
5a.Well Location: 13.0 ft' 27.0 ft. BROWN SANDY SILT
CLIFFSIDE STEAM STATION 27.0 It. 55.0 ft' BROWN SILTY PWR
Facility/Owner Name Facility ID#(if applicable) 55.0 ft. 67.0 ft. WHITE/GRAY ROCK
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL•-40.0-52.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK***
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 50.66" N 810 45' 12.35" W A',-, 05/02/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!5No I5A NC'AC 02C.0100 or 15A NCAC 02C,.0200 Well Co
If this is a repair,fill out known well construction hilbrntation and explain the nature of the of this record hasbeen provided to the well owner. E M
repair under 2/remarks section or on the back of this farm. 666...��T
23.Site diagram or additional well'details: AA,,lLv
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additioRAYedoOrtMinfo
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 I NWAOM PfCOWsaing Uri
9.Total well depth below land surface: 65.0 DWOMOd
l-ar mtdriple wells list all depths;fffe d rent(example-3@100'and 1 cc (ft)100) Submit this GW-1 within 30 days of well completion per the following:
17.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
/f water level is above caving,use"' Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 6 1 7
"
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-L'oop 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,tNC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018