GW1-2022-09027_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r l/1/sdj 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
'Well Contractor Certification Number P !~'.
^ 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
in.
Company Name _ v
2022 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. Lou in,.rState�Yaridx�e,etc.) tt. Q ft. ! in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3� ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation El We]Is> 100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD AMOUNT
Non-Water Supply Well: 3 c> tt. Q ft. 80 S' Jpw/ ROSS Rbt`T1A.-
❑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 ft. 3 0
❑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 ft. To ft. DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed$-fir;- Well ID# ` ft. ft. EL
5a.Well Location:
Duke Energy
l>ility/Owner Name Facility fD#(if applicable)
rt. rt.
306 Dunnaway Road, Semora, NC 27343
Physical Address,City,and Zip ft. ft.
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:
N W
6.Is(are)the well(s)• ❑Permanent or ckTemporary Signature of Certified Well Contractor Date
fiv signing this Porn:.1 herebv certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
IJ this is a repair,fill out known well construction information and explain the nature of the 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-I 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: (t-TJt') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it diJJerent(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: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/floater level is above casing,us/e'"+" 1
Jo 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: Sic 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: k
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019
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