GW1-2022-08654_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES, r
Well Contractor Name FROM TO DESCRIPTION
A - 4226 ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER'if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0.0 rt• 55.0 ft. 6.0 C SCH 40 PVC
16.INNER CASING OR TUBING eothermal closed-l000l
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permtis(i.e. U1C,County,State,Variance,eie.) 0.0 rt• 83.0 ft- 2.0 !. in SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 83.0 rt• 93.0 rt• 2,0 in. 010 SCH 40 PVC*
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) lS.-GR'OUT
❑lm atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 tt. 59.6 ft- AQUAGUARD SLURRY
TMonitoring ❑Recovery 0.0 ft- 55.0 ft. PORTLANOBENTONITE SLURRY
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 75.0 ft. 96.0 f- 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 soiVrock e,gmin size,etc.
0.0 rt• 175.0 rt• i NOT DRILLED BY GEX
4.Date Well(s)Completed: 04/29/22 Well ID# MW-11 BR ft. ft.
Sa.Well Location:
ft. tt.
CLIFFSIDE STEAM STATION
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel identification No.(PIN) BENTONITE SEAL- 59.6 75.0 FEET&96.0- 175.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***U-PACK***
(ifwell field,one IaUlong is sufficient) 22.Certification:
350 12' 51.01" N 810 45' 12.42" W "_ 05/02/22
6.Is(are)the well(s): (EPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,l hereby certify that the ivell(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or I5A NCAC 02Q0200 Well Cons uWZta arcs and that a copy
If this isa repair,Jill out known Krell construction information mid explain the nature of the of'ihis record has been provided to the Krell inviter. � /�
repair under renuhrkx sectiat or on the back of7his form.
"RN ,
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 additiorMll cpn uefj 9�}fi fo
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pag II`nCeSsary.
drilled: 24.SUBMITTAL INSTRUCTIONS mamnq UM
9.Total well depth below land surface: 93.0 (ft.)
par multiple wens list all depths ifdifferent(example-3 rOt 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 35.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lf'ivaier level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
SONIC/HQ CORE
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 over 100,000 GPD:Copy to DWR,CCPCUA
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13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,iNC 27699- 611
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13b.Disinfection type: Amount:
Finn GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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