GW1-2022-09026_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well ontractor information:
14.WATER ZONES
WeIlContractor Name FROM TO DESCRIPTION
rt. rt.
-Nl.Well Contractor Certification Number F n
S_P D i ZQ22 15.OUTER CASING for multLcased wells OR LINER if a licable
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. i in.
Company Name {f)ivi iTay%+« 1 '`' '„ 1 Uln?
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,Counlr,State. Variance,etc.) 3'� ft. r(� ft. in.
3.Well Use(check well use): R. ft. i 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. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
onitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Regiediation �19.SAND D/G E ft. if B $ ( 3r /
RAVEL 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 necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: ��_1 Well iD# P Z-f 0
Sa.Well Location:
rt. rt. Ivw
Duke Energy
_zility/Owner Name Facility iD#(if applicable) ft. ft.
ft. ft.
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip ft. ft.
21.REMARKS
Gaston
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)- ❑Permanent or SUemporary Signature of Certified Well ContraceP, Date
By signing this form,i herebv certift,that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or [!lNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this 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 hack 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiferent(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: (ftJ information Processing Unit, 16117 MSC,Raleigh,NC 27699-1 6 1 7
If water level is above casing,use
d+"
11.Borehole diameter: SAD (in,) 24b. For Injection Wells: Copy to DWR,Underground injection Control(iUC)
C Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
�,DR WATER SUPPLY WELLS ONLY: 24d.For Water We11s producin>;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
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