GW1--03370_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
NICHOLAS HAYES
14.R'ATER ZONES 1
Well Contractor Name FROM TO'- DESCRIPTION
A - 41:21 fr. ft.
NC Well Contractor Ceniftcatioir Number :15.OUTER CASING for multi-cased wells OR LINER(if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER- .. .THICKNESS MATERIAL
0.0 ft- 217:0. ft- 8.0 i in. SC'
Company Name NameH 80 PVC
W R03001 24 16.INNER CASING OR'FUBING geothertnal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.1//C,County,.Siate,Variance,etc.) - ft. ft. in.
3.Well Use:(check well use): ft. rt. in:
Water Su I Well: 17.SCREEN
PP.Y FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling supply) ❑Residential Water Supply(single) ft ft in:
❑industrial/Commercial OResidential Water Supply(shared) IS:GROUT
❑Irri ation.,. ❑Wells>100,000 GPD FROM TO MATERIAL.. .EMPLACEMENTMETHOD&AMOUNr
Non-Water Supply Well: . 0,0 fr. 2170 ft' NEAT PORTLANDCEMENT SLURRY(PUMP)
8Monitoring ❑Recovery rr. ft:'
Injection Well:
❑Aquifer Recharge OGroundwater Rerhedi6tion
19.SAND/GRAVEL PACK ifa rhiablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
OAquifer Test f7Stormwatei Drainage D. H:
.. .. .
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO 'DESCRIPTION(color;hardness;soillrock 1- e, rain size,elc. '
❑Geothermal(Heating/CoolingReturn) ❑Other(explain'under#21 Remarks)
0.0 ft. 25.0 tr. RED CLAY
4.Date Well(s).Completed: 04/04/23 Well ID# EX-68 25.0 ft. 55.0. 1" RED SANDY SILTY CLAY
ia.Well Location: 55.0 ft' 69:0 . ft' BROWN CLAY
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 69.0 ft 207.0 ft• PWR
Facility/Owner Name Facility ID#(ifapplicable) 207.0 ff 230.0 ft' ROCK
253 PLANT ALLEN ROAD .B.ELMONT 28012 ft.
Physical Address,City,and Zip ft. ft.
GASTON 304337 .21.REMARKS'
County Parcel Identification No.(PIN) OPEN HOLE
5b.Latitude and longitude in degrees/minutes/seconds or decimal dedrecs:
(if well field,one lat/long is sufficient) 22.Certification:
524810.713.52 N 1400509.72649 W 04/13/23
6.Is(are)the well(s): OPermaneot or OTemporary Signature ofCeitified Well Contractor Date
By signing this form,1 hereby certify'drat the wel/(s)sras(were)cons t + 44d irneca c ance with
7.Is this a repair to an existing well: ❑Yes or l!lNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200[Yell Construction S7a,nla�Ind til+ l'o�y Ai,,
lfth[s is a repoir,fil!out known well construction information and explain the:na++re ofrhe
ofilds retard has been provided to the steel/owner. C i spy 3 a ?
repair under'=21 reararks section or on the back nflhix jorur.
. ...:
23.Site diagram or additional well details: MAY ^'
8.For Geoprob6l)PT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page to provide additional well construJi.47-'2323
construction,onlyI GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach aci aa.g�if ecessary.
drilled: ana. r Lr
G 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 230.0 (ft.)
For multiple we/ls fist all depilis ifdi jerent(example-3 a 700'and 1@100') Submit this GW-1 within 30 days of well completion per the rollow;ing:
10.Static water level below top of casing- ARTESIAN 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft:) Information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
lflrater level is abm•e casing.-axe•; ..
12.0/7.0 24b. For Injection Wells:Copy to DWR,Underground injection Control (lUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY/AIR
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct path,etc.) county environmental health departmeht 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 27699-161 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