GW1-2022-09018_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
py 14.WATER ZONES
Well Contractor Name FROM TO DESCR.IPTION
R
q� _
Well Contractor Certification Number _ 15.OUTER CASING for multi-cased wells OR LINER tf a licable
Cascade Drilling, LP -� J v � FROM TO DIAMETER THICKNESS MATERIAL
ft, ft.
Company Name ' M,
If1i�TqOC
4 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.Coun(r.State. Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑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: ft. O ft. Po(7/(rJ
6"onitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑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,soil/rock e, rain size,etc.
q ft. ft.
J /Q 4.Date Well(s)Completed: fig- LZ ft. ft.Well ID# � ` �a
Sa.Well Location: ft. ft.
Duke Energy ft. ft.
,ility/Owner Name Facility ID#(if applicable) ft. ft.
306 Dunnaway Road, Semora, NC 27343 ft. ft.
Physical Address,City,and Zip ft. ft.
Gaston 21.REMARKS
.
County Parcel Identification No.(PIN) A / �' cv- I' j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 9��
g Ls z�
6.Is(are)the well(s): ❑Permanent or (:Wemporary [ ature of Certified Well Contractor Date
By signing this Jornn.I herebv cerli6,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!JNo 1 SA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
IJ'this is a repair.Jill out known well construction infornnation and explain the nature ofthe oJ'this record has been provided to the well owner.
repair under#21 remarks section or on the back oJ'thisJornn.
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 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 iJ'diJjerent(example-3@200'and 2L100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fo Information Processing Unit, 16117 MSC,Raleigh,NC 27699-1617
IJ water level is above casing,use"+"
11.Borehole diameter: (inJ 24b. For Injection Wells: Copy,to DWR,Underground Injection Control(HJC)
Program, 1636 MSC,Raleigh,NC 27699-1636
-»�!
1.e Well construction method: C
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
r)R WATER SUPPLY WELLS ONLY: 24d.For Water Wells produci Ig over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
I r So
r•, �
13b.Disinfection type: Amount: V v V_
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018