GW1-2022-08668_Well Construction - GW1_20220427 (2)

i
_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
I.Well Contractor Information:
KENNY SARGENT 14.WATER70NES
Well Contractor Name FROM TO I DFSCRIPrION
ft. fr.
A -4226
n. n.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cared watts OR LINER if a Iieable
GEOLOGIC EXPLORATION FROM TO DIAM1fEfER THICKNESS MATERIAL
fit. [r. in.
Company Name
l6.INNER CASING ORTUBING eorhermalc[med-too
2.Well Construction Permit 4: FROM TO DIAMETER I THICKNESS MATERIAL
Lkt all applicable is construction perntirs Ii.e.II1C,County,Slate,Variance.eta.) 0.0 fr. 3.0 ft. 2.0 '"• SCH 4O PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public 3 0 fit• 13.0 r' 2,0 in. .010 SCH 40 PVC
DGeolhermal(Heating/Coo ling Supply) OResidential Water Supply(single) ft. I n, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
Dlrri ation OWells> 100,000GPD FROM TO AtATER1AL EMPLACEMENT MM.IOD&AMOUNT
Non-Water Supply Well: 0.0 fr. 1.0 r' AQUA GUARD SLURRY
®Monitoring ❑Recovery ft. ft.
Injection Well:
fit. fit.
OAquifer Recharge OGroundµaler Remediation
19.SAND/C RAVEL PAC K Ira licable
OAquiler Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.5 fit 16.0 r'' 20-40 FINE SILICA SAND
OExperimental Technology ❑Subsidence Control fit. ft.
OGeotherrnal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheep If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardrim soiltrock type,stritin sae,etc.
0.0 f' 1.0 f' GRAVEL
4.Date Well(s)Completed: 02/02/22 Well IDk PMW-AS-SS 1.0 fit• 9.0 fir• RED SILTY CLAY
5a.Well Location: 9.0 rt. 16.0 R' `m '}sl T*
CLIFFSIDE STEAM STATION rr. rr.
FacilitytOwner Name Facility IDII(irapplicable) ft. ft. APR Z `
573 DUKE POWER ROAD MOORESBORO 28114 ft, ft.
Physical Address,City,and Zip R. ft, p�:ie`s' `i;'•� }G IJ\ j
l
RUTHERFORD 21.RENIARKS
County Parcel Identification No(PIN) BENTONTTE SEAL•-1.0-2.5 FEET/SUMP_ 13.0-16.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Cerlifrcatior
35" 12' 52.92" N 810 45' 14.33" W
03/23/22
b.Is(are)the well(s)• Milermanent or OTemporary Signature of Certified Well Contractor Date
By.signing this farm.I herchy certify dnoe die well(s)ryas(i rcre)consinuted in accrrdarire frith
7.Is this a repair to an existing well: Dyes or MNo l5A N(A('02('.0100 or ljA N(A('02('.(1200 Yell('onurtictio)7 Siorulards attd lint a etrpy
ifdik is a repair.fill our knows vet/construction hybrmation and explain the nature rifilre ofriri.s record has been provided to rise null owner.
repair under 1121 renrarkr section or on the back oflhis farm.
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 µells (add'See Over'in Remarks Box).You may also attach additional pages if necessan.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 (ft.)
14u nothiple yells list an depths ij'drlferent(aronrpte.3@(D20i)'and 2 a i00.) Submit this GW-I within 30 days of well completion per the following:
8.27 24a. For All Wells: Original farm to Division of Water Resources (DWR).
j'u'anr Irrel it share casing,ruse"'"Smile water level below top of casing: (ft•) information Processing Unit, 1617 MSC,Raleigh,NC 27699-1 6 1 7
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11,Borehole diameter; 6.0 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(it:C)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC t
24c.For Water Su 1 and O en-Loo Geothermal Return Wells-Copy to rile
(i.e.auger,rotary cable,direct push,etc) county environments heat apartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduc(n over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, bt I MSC,R.
cigh,NC 27699-161 I
13a.Yield fgpm) Method of lest:
13b.Disinfection type: Amount:
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Fonn G W-I North Carolina Department of Environmental Quality-Division of Water Resources Rev"aed 6.6.2018