GW1-2022-09028_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Wel Contractor Information:
Z( 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
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'--� :Well Contractor Certification Number rl F = /n 1n1 15.OUTER CASING for multi-cased wells OR LINER if a licable
Cascade Drilling, LP SEP 202 FROM TO DIAMETER THICKNESS MATERIAL
rt. ft- in.
Company Name c
1{1r'Uf"rTv��"'1 ,iry° ,P�•::',J (�ili
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,County,State. Variance,etc.) 44 3 ft. ft. ! in.
3.Well Use(check well use):
ft. ft. in.
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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
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 43 ft- '> ft. 'ie.11 S-,-Vs 3 OJ5� p0mar';tl
Monitoring ❑Recovery ft. ft.
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 necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil rock e, rain size,etc.
ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location:
Duke Energy
ility/Owner Name Facility iD#(if applicable) ft. ft.
306 Dunnaway Road, Semora, NC 27343
rt. tt.
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:
(if well field,one lat/long is sufficient) 22.Certification' e
N W 1-41
6.Is(are)the well(s)• ❑Permanent or '?gemporary Signature of Certified Well Contracto Date
By signing this form.I herebv certify 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.0200 Well Construction Standards and that a copy
If this is a repair,Jill 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: 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 if d(/Jerent(example-3@200'and 2@100')
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24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
10.Static water level below top of casing: Lz� Information Processing Unit, 16117 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in,) 24b. For injection Wells: Copy,to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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
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)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:
I
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13b.Disinfection type: Amount:
j.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour ces Revised 6-6-2018
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