GW1-2023-00649_Well Construction - GW1_20230105

WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
1.Well Contractor Information: f
NICHOLAS HAYES 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. ,
A - 4121 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ilicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
0.0 R• 74.0 fr• 8.0 SCH 80 PVC
Company Name 0.0
INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: WR0300123 FROM TO DIAMETER THICKNESS AATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells> 100,000 GPD FROM I TO MATERIAL EMPLACEMENTDIETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 74.0 ft- NEAT PORTtANDCEMENT SLURRY
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) fJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
0.0 fr• 50.0 fr. BROWN SANDY SILT
4.Date Well(s)Completed: 10/28/22 Well ID# EX-406R 50.0 fr• 640 R' PWR
sa.Well Location:
64.0 fr. 241.0 f" ; ROCK
DUKE ENERGY OF THE CAROLINAS MARSHALL STEAM STATION
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
8320 NC HIGHWAY 150 SHERRILLS FORD 28673 rt. ft.
Physical Address,City,and Zip ft. ft.
CATAWBA 461803426350 21.REMARKS
OPEN HOLE
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: f/I�
350 35' 41.80" N 800 57' 54.15" W A/A 12/14/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify dint the well(s)was(here)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
/f finis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the we//gtrner. '^
repair under"21 remarks section at•on the back of this form. �
23.Site diagram or additional well detuiI
d �. r t:-.�9
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide aitional well construction info
construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may alsp tgclwdg tirnln-es if necessar,
drilled: 24.SUMMITTAL INSTRUCTIONS J) �IVV UU LLI��I
241.0
9.Total well depth below land surface: (ft.) lwe _
For nwiiple wells list all depihs ifdierent(example-3@200'aml2 a 100� Submit this GW-1 within 30 days of weYl cOmptc�tiOt�T j er (fie f0110wing:
9.1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If crater level is above casing,use"-
i I.Borehole diameter: 16.0/7.0/12.0 (in) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (lUC)
Program, 1636 MSC,Raleigh,NC 2769971636
12.Well construction method: AUGER/AIR ROTARY
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
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