GW1-2022-09025_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information:
14.WATER ZONES
Well
Contractor Name FROM TO DESCRIPTION
�� • �►� � (� ft. ft.
Well Contractor Certification Number SF P '2 15.OUTER CASING for multi cased wells OR LINER if a licable
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
g Irii:yi~i. hi �' r .:, U,*I,, ft. rt. in.
Company Name
16.INNER CASING OR TUBIN .(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public cit. �0 ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: S� ft. O rt. R013�ja,491m �
onitoring ❑Recovery ft. ft.
injection Well: ft. ft.
❑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: 5'-l9 Well iD# P
5a.Well Location:
Duke Energy �� rt. 0 ft. f l�
:ility/Owner Name Facility iD#(ifapplicable) �� rt. ft. h
306 Dunnaway Road, Semora, NC 27343 rt. '�-a ft.
Physical Address,City,and Zip ft. ft. 01 OM 0-1, hor-
Gaston 21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: Q
N W /_� A,"� (J
6.Is(are)the well(s)- ❑Permanent or zRTemporary Signature ofCerhfied Well Contractff Date
Av signing this form,I herebv certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11No 15A NCAC 02C.0100 or 13.4 NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out known well construction information and explain the nature oJ'the oJ'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 if necessary.
drilled: C 24.SUBMITTAL INSTRUCTIONS
o�
9.Total well depth below land surface: A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iJ different(example-3@200'and 2@100')
i
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
1J'water level is above casing,use"+" -
11.Borehole diameter: }uso (in•) 24b. For Injection Wells: Copy to DWR,Underground injection Control(iUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i
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 WATER SUPPLY WELLS ONLY: {
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018