GW1-2022-08661_Well Construction - GW1_20220427

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a rlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fr. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well CDnstrueticin Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,Comuv,State,Variance,etc.) 0.0 rt• 8.0 ft. 6.0 in. .188 STAIN LESS STEEL
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft' 38.0 ft' 6.0 in. .010 .188
STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in,
❑Industrial/Cotntmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wel Is> 100,000 GPD FROM TO MATERIAL EMPLACEM ENT M ETHOD B AMOUNT
Non-Wafer Supply Well: 0.0 ft- 1.0 ft- AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge MGroundNvater Remediation
19.SAND/GRAVEL PAC K ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquiter Test ❑Stormwater Drainage 5.0 rt• 39.0 r`' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type, rain size,elc.)
0.0 rt• 19.0 ft. RED/BROWN SILTY CLAY
4.Date Well(s)Completed: 02/17/22 Well ID# EX-AS-11 19.0 ft- 39.0 r' ROCK
Sa.1Vc11 Location:
ft. rr.
CLIFFSIDE STEAM STATION
Facility/Owner None Facility 1D#(if applicable)
rt. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft. APR 2 7 2022
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS r.;;+:'7 h: ,Irk
County Parcel Identification No.(PIN) BENTONITE SEAL 1.Q•rSOI,fEE�fSU�G[PiOr'�i39OLf�ET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 52.15" N 810 45' 12.93" W /4 �y 03/23/22
6.Is(are)the well(s): [NPermanent or ❑Temporary Signature of Certified Well Contractor Date
Bj,sign/ng this/ihrn,I hereby certify that the well(.)was(were)constructed in accordance,ridr
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a cupj-
lfthis is a repair.fill out known well c•onsrntcrion in/brmmion and explain the nature ofthe c fthis record has been provided to the well owner.
repair under 421 remarks section or on the back q/'thix/brm.
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-I 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: 39.0 (ft.)
I•br multi le pre/le list a//depths i d, > > Submit this GW-1 within 30 days of well completion per the following:
P p f lle+'em(example-3 rh-tl0'mu(-r7/00')
10.Static water level below to of casing: 1.31 24a. For All Wells: Original form to Division of Water Resources (DWR),
if lrnter/ere/is ahnre casing,use"-
p (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
16.0/6.0 24b. For Injection Wells: Copy to DWR, Underground Injection Control ((UC)
Program, 1636 MSC,Raleigh,NC 2 7699-1 636
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 FVATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.field(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department or Environmental Quality-Division or Water Resources Revised 6-6-2018