GW1--03372_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
NICHOLAS HAYES 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A - 4121
rc. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LiNER(if a tlicablC)
GEOLOGIC EXPLORATION FROM TO DIAMETER TIIICKNESS M:\TERI:\L
0.0 ft. 1.166.0 ft. 8.0 i" SCH 80 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: W R0300124 FROM TO DIAMETER THICKNESS MATERIAL
1,i.st all applicable wel construction permits(i.e.U1C,County,State,liariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE - TIIICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. ft. in.
❑Geothermal(Pleating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial OResidential Water Supply(shared) 13.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL ENIP1 ACEMENT METHOD 3 Ah1OUNT
NDn-Water.Supply Well: 0.0 ft• 166.0 ft WATPORTLANDCEMENT SLURRY(PUMP)
[EMonitoring ❑Recovery fr. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
..19.SAND/GRAVEL PACK ifa tlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL Eb7PLACENI ENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑l racer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks)
0.0 fr• 33.0 ft- RED CLAY
4.Date Well(s)Completed: 04/12/23 Well ID# EX-67A 33.0 ft• 92.0 ft. BROWN CLAY/PWR
in.Well Location: 92.0 ft- 150.0 ft' PWR
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 150:0 ft• 230.0 ft. ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
253 PLANT ALLEN ROAD BELMONT 28012
Physical Address,City,acid Zip ft. ft.
GASTON 304337 21.REMARKS
County Parcel identification No.(PIN) OPEN HOLE
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long sufficient) 22.Certification:
525224.54268 N 1400536.17681 W l "16
04/13/23
6.Is(:re)the wCll(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ifthis is a repair,fill ow known we/1 construction infimnatlon and explain the nature ofthe oj'this record has been provided to the ire0 olrner.
repair under..21 remarks section or on the back of7his form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction inly
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach admhy"'I1P.-I ifjyzjaq'.
drilled: 24.SUBMITTAL INSTRUCTIONS LUU
0
9.Total well depth below land surface: 230. (ft.) IR�f,r
1•br nwhiple wells list all depths if dijjerew(example-3 a 200'and 2@100') Submit this GW-1 within 30 days of well completion perWQ&-1iIj-:
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 2769971617
1f venter level is abore caving.use .,
11.Borehole diameter: (in.)
12.0/7.0 24b. For Injection Wells: Copy to DWR,Underground Injection Control.(1UC)
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 push,etc.) couny 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 27699-161 1
13a.Yield(gpm) Nlethod of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2013