GW1-2022-08657_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. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a tlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Irell cattsirtictioa ptrniild'(i.e.U1C,Count),,State.f'arianc•e,etc.) 0.0 ft• 12.0 ft. 1 6.0 " .188 ISTAINLESS STEEL
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12.0 ft. 102.0 ft' 6.0 in.
.010 .188
STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTiMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft. AQUA GUARD SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge MGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 7.0 ft• 103.0 f`' 20-40 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 421 Remarks) FROM TO DESCRIPTION color,hardness,sail/rock type, fain sim,etc.
0.0 f` 4.0 f` RED CLAY
4.Date Well(s)Completed: 02/03/22 WcI11D# EX-AS-3 4.0 f+• 55.0 ft SAPROLITE
$a.Well Location: 55.0 82.0
ft. ft.
a ; rC- ,
CLIFFSIDE STEAM STATION 82.0 ft• 103.0 ft• R
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address,City,and Zip ft. ft. C-e,�,�•s.,,,ry9 v ., 6•-��V�a�"rn?Efi+;<t'+1�'ti
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL•- 2.0-7.0 FEET/SUMP - 102.0-103.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
350 12' 48.51" N 810 45' 12.47" W110V 03/23/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signhk this form,/herebj,ceritfj,that the ireN(s)was(were)c•onsirucled in acc•arclaac•e frith
7.Is this a repair to an existing well: 01'es or MNo 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Wel/Construction Standards and that a cant
//ibis is n repair,fill nw known well conrn uc tioa ii j nnaion and ezp(nin die nnnire of dte ofthis record has been provided to the well owner.
repair under"21 remarks s•eclion or on the hack gfthis 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 I 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: 103.0 (ft.)
h'or nwhiple ire//s/i.s/all depths ifdiOirem(example-3 a 2a0'and 2@ron') Submit this GW-1 within 30 days of well completion per the following:
24.73 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
ll irater level is above c•asinl!,use"a-
11.Borehole diameter: 16.0/6.0 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC/AUGER/AIR
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.field(gpm) n9ethod of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018