GW1--03399_Well Construction - GW1_20230517

WELL CONSTRUCTION RECORD(GW4) For Internal:Use Only: $
1.Well Contractor Information:
BRIAN THOMAS ia.WATER ZONES.
. "
Well Contractor Name
FROM ,to - DESCRIPTION -
'ft.
A _ 2581 p6 i .
ft.. ft. [.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased,wells OR LINER if a rlicablc
GEOLOGIC EXPLORATION- FROM TO.'. DIAMETER THICKNESS I MATERIAL
ft. fi. M.
.. .
Company Name -
WR0300124 16.INNER CASING OR TUBING geothermal closed-loon -
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I NZATER1AL
Lisl ail applicable trell construction permits(i.e.UIC,Count);Stole,Variance,etc.) 0.0 ft. 75.0 ft. 6.0- in. SCH 86 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR M REE TO DtANIETER SLOTSIZE THICKNESS. MATERIAL
l7Agricultural ❑Municipal/Public 75.0 tt' 105.0. ft' 6.0. 'n'" .010 SCH 80 SS
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. :ft.
❑industrial/Commercial q ❑Residential WatetSupply(shared) 19,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 00 ft. 65.0 ft. NEAT PORT AND CEMENT SLURRY(PUMP)
OMonitoring ❑Recovery ft. R.
injection Well:
' ft.❑Aquifer Recharge ❑Groundwater Remediation ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PAC '(if atiiplicliblc)
FROM TO i I MATERIAL EMPLACEMENT NIETHOD
❑Aquifer Test ❑Stormwater Drainage 70.0 ft. .107.0 ft. 7-35(#2) . POUR
❑Experimental Technology O.Subsidence Control ft: ft.
❑Geothenmal(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 type,grain size,etc.)
0.0- ft. 10.0 ft. RED SILTY CLAY
4.Date Well(s)Completed: 12/30/2- Well ID# EX-25 10.0 ft. 21.0 ft. BROWN SILTY SAND
5a.Well Location: 21.0 ft. 79.0 tr. TAN/WHITE SILTY SAND
DUKE ENERGY OF THE CAROLINAS ALLEN STEAM STATION 79.0-ft. 105.0 ft. PWR .
Facility/Owner Name Facility ID#(if applicable) 105.0 ft. 119.0. ft' ...ROCK 7Yti.
253 PLANT ALLEN ROAD BELMONT 28012 ft. ft. �-- >
Physical Address,City,and Zip: ft. ft. M Y y ty
2023,
GASTON 304337 21.REMARi S n I 1 /
County Parcel Identification No.(FIN) BENTONITE SEAL-65.0=70.01Rk`fix M-ice.:�.
Sb.Latittiile and longitude in degrees/iirinutcs/seconds or decimal degrees:
STAINLESS STEEL SUMP- 105.0- 106.0 FEE '-"-
(if well field,one]at/long is sufficient)
22.Certification:
528601.69689 N 1400243.20504 W !:2/Sn:E,.. '^'`" 04/11/23
6.Is(are)the vsell(s): OPermanent or ❑Temporary Signature of Certified Well Contractor 7Date
By sighing this form,1 hereby certify dial the wells)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction S'ainlards and that a copy
Ijtbis is o repair,fill out known Well construction information anti explain the nature oftye oj'this record has been provided to the ire/1 otrner.
repair under a21 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: 106.0 (ft.) -
Fbr to dtiple wells list all depths iftli)jerew(example-3@200'and 2 a 100') Submit this GWA within 30 days of well completion per the following:
10.Static water level below top of casing: 24.0 (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
if water/ere/is above casing,use - Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
14.0/10.0/6.0 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: AUGER/AIR/SONIC
24c.'For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,�.otaty,cable,directpush,'etc.) county environmental health department of the county Where installed
FOR 1y'ATER_SUPPLI'WELLS ONLY: 24d. For Water Wells producing over 100,060 GPD: Copy to DWR,CCPCUA
Perrrilt Program, 1611 MSC,Raleigh;NC 27699-161 I
13a.Yield(gpm) Method of test:.
13b.Disinfection type: Amount:
Forin GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1, Revised 6-6-2018
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