GW1-2022-09010_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well f
ontractor Information:
4, 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`wells OR LINER if a licable
Cascade Drilling, LP C 2f12_ FROM TO DIAMETER THICKNESS MATERIAL
� � ft. ft.
! in.
Company Name
^S' 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: {n+ ""° FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Count•.Sta e.Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed- ! L: - Well iD# / Z
5a.Well Location:
Puke Energy
Energy
r'zility/Owner Name Facility iD#(if applicable)
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip
Gaston 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification•
N W g`
6.is(are)the well(s):tg Permanent or ❑Temporary Signature of Certified Well Contract Date
By signing this form,l herebv certifv that the wells)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or It No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdierent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fit.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use'•+" I
IL Borehole diameter: (in.) 24b. For injection Wells: Copy to`DWR,Underground injection Control(iUC)
Program, 1636 MSC,Raleigh,NC 2 7 699-1 636
12.Well construction method: 5�r t�G
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
/t e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
':)R WATER SUPPLY WELLS ONLY: 24d.For Water Wells Water Wells producing)e'r 100,000 GPDer 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018