GW1-2022-08663_Well Construction - GW1_20220427

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
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ilicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERL\L
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(i.e.UIC.Cmtnly,State,Variance,etc.) 0•0 ft• 9.0 R. 6.0 in. .188 STAINLESS STEEL
3.Well Use(check well use): ft. I in.
Water Supply Well: FRSCREEN, TO DIAMETER SLOTSIZE THICKNESS DATERIAL
❑Agricultural ❑Municipal/Public 9.0 ft. 64.0 ft• 6.0 in- .010 .188 STAINLESS STEEL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑lrrl ation ❑Wei Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr• 1.0 ft- AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge MGrortndwater Relmediation
19.SAND/GRAVEL PACK ifa ilicable
❑Aquifer Storage and Recovery ❑Salinity BarrierJRe,,ak,,)
FROM TO MATERIAL EYIPLACENIENT METHOD
❑Aquifer Test ❑Stortm\vater Drainage6.0 ft. 65.0 fr• 20-40 FINE SILICA SAND
El Experimental Technology ❑Subsidence Control ft. ft.
❑Gcothertmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 FROM TO DESCRIPTION color,hardness,soil/rock type, iain size,etc.)
0.0 ft. 39.0 ft. PWR
4.Date Well(s)Completed: 01/31/22 Well ID# EX-AS-6 39.0 ft. 41.0 fr. FINE SAND
na.Well Location: 41.0 ft• 44.0 ft' COARSE SAND
CLIFFSIDE STEAM STATION 44.0 rr• 65.0 fr• ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft. 'F'
573 DUKE POWER ROAD MOORESBORO 28114
Physical Address.City,and Zip ft. ft. /t (�
RUTHERFORD 21.REMARKS H f� `
County Parcel Identification No.(PIN) BENTONITE SEAL_ 1.0 6.0 FEET/5UM �6p4��0.;�65.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvell field,one]at/long is sufficient) 22.Certification:
3S° 12' S2.00" N 81° 45' 13.15" W � f 03/23/22
6.1s(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this finun,1 hereb y cert Jy that the well(i)irar(were)cmu'truc•ted in accorchnic•with
7.Is this a repair to an existing well: ❑Yes or ONo 15A 1VC'.4C 02C.0100 or 15A NCAC 02C,.0200 Well Gnhrtructinn Smndnrdc aucl that a copy
if this is a repair,fill out known ire/I conrwu•Bmh hh/i,rnhation and e.rplain the nantre t1/'the of'this record has been provided to the well ou ner.
repair under 2/remarkr section or on the back ofthis•farm.
23.Site diagram or additional well details:
S.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: 65.0 (ft.)
For mulliple irelis list all depths ifdi/Ja ens(ecainple-3@200'and?rt 100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 9.82 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If u'oier level IS above casing.use"-
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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(gym) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018