GW1-2022-08668_Well Construction - GW1_20220427

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4121
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
Lisi all applicable well construction perndls(i.e.U1C,Cotmly.Stare,Variance,o1ct) 0.0 B- 18.0 ft. 6.0 In' ,188 STAINLESS STEEL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18.0 ft' 98.0 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) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 B- 8.0 ft- AQUA GUARD SLURRY
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge [EGroundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13.0 ft• 99.0 fr' 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,soillr•ock type,grain sae,etc.)
0.0 fr, 17.0 ft• RED CLAY
4.Date Well(s)Completed: 02/16/22 Well ID# EX-AS-8 17.0 fr. 67.0 ft- SAPROLITE
>a.Well Location: 67.0 fr' 78.0 rr' PWR
CLIFFSIDE STEAM STATION 78.0 rt• 990 fr• ROCK
Facility/Owner Name Facility ID9(irapplicable) �-
573 DUKE POWER ROAD MOORESBORO 28114 rr. ft.
Physical Address,City,and Zip
ft. ft. 4 P R
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-8.0-13.0 f,, ET/S,U,N r7,98.0-99.0 FEET
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 12' 52.41" N 810 45' 13.36" W /4/ � 03/23/22
6.Is(are)the well(s): (EPermanent or ❑Temporay Signature ofCertified Well Contractor Date
B),signing this Jinn,I hereby certify ilia''Ile u•e/l(r)wax(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Consiruc•tion Standards and that a copy
//7his is a repair,fill out known well c•onxiruc•tion h formation and explain the nature(y'the of this record has been provided to the well owner.
repair under'121 reniarkr section or on the back oJ7his Jinn.
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 1 GW-I is needed. Indicate TOTAL NUMBER of%vells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 99.0 (ft.)
/•br inuhiple sells list all depths i'eh(Jeren1(example-3 a 200'and 2 a100') Submit this CW-1 within 30 days of well completion per the following:
25.84 24a. For All Wells: Original form to Division of Water Resources (DWR).
Static water level below top of casing: (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
lf u'nler level is nbore c'osing,use"r"
11.Borehole diameter: 1 6.0/6.0 (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-Loon 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.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount:
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018