GW1-2022-09030_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information:
14.WATER ZONES
!y/ FROM TO DESCRIPTION
Well Contractor Name �-a y �"� ft. ft.
±;Well Contractor Certification Number S F P A. v 2022 15.OUTER CASING for multi-cased'wells OR LINER if a licable
Cascade Drilling, LP ~ FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company {fti,i
P y Name 16.INNER CASING OR TUBING'(geothermal closed-loop)
2.Weil 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): ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if appiicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it. it
❑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,gnin size,etc.)
ft. ft.
4.Date Well(s)Completed:'J _-Z-t- Well iD#
5a.Well Location:
Duke Energy
cility/Owner Name Facility iD#(if applicable) ft. ft.
306 Dunnaway Road, Semora, NC 27343 rt. ft.
Physical Address,City,and Zip ft. (t.
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:
N W
6.is(are)the well(s)' ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form.Iherebv certiJB that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or CtNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
67his is a repair,Jill out known well construction information and explain the nature ofthe at this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 Bok).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ir-21 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(a,)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
/J'wa[er level is above casing,use"+"
24b. For injection Wells: Copy to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in,)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Op n-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 produci Ig over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019