GW1--01585_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
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This form can be used for single'or multiple wells
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1.Well Contractor Information: .
14.WATER ZONES ' .
Oliver Pederson FROM TO DESCRIPTION
Well Contractor Name - . ft. _ It - No Water in boring
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_4481-A • • `L_ ft. I ; ..
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap•licable) -
FROM " TO "" DIAMETER .THICKNESS MATERIAL' .
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•Cascade Drilling ft. ft. i°:•
• Company Name 16.INNER CASING OR TUBING(geothermal closed loop) '
.FROM : TO .•.DIAMETER. THICKNESS. . MATERIAL .
2.Well Construction Permit#: ft. ft. in.:
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
.•..3.Well Use(check well use): 17.SCREEN •
Water Supply Well: • FROM'' , TO . DIAMETER 4 SLOT SIZE THICKNESS MATERIAL
❑Agricultural . ❑Municipal/Public ft. ft. t"•
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❑Geothermal(Heating/Cooling Supply) DResidential Water Supply.(single) ft. It: in.+
❑Industrial/Commercial ❑Residential Water Supply(shared) - 18,GROUT •
FROM. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-- . olrrigation. _ _ . . .. _ - —O- "ft.._ 57' .ft.. • - •
Non-Water Supply Well: • .. . .
ft.' ft.
❑Monitoring_ '. ❑Recovery • . . . '
Injection Well: . ft. ft. .
❑Aquifer Recharge - ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
.FROM' TO . .MATERIAL EMPLACEMENT METHOD
l7Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
• ❑Aquifer Test • DStormwater Drainage •ft ft.
DExperimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)•.••. ' . •
DGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) XOther(explain under#21 Remarks) 'tL ft. i' ;
`L `t• • No Samples taken
4.Date well(s)Completed?-16-2024wellm# INCL - 5 --- --rt It
sa.Well Location: -Drilled through a concrete
ft. `L pillar
Duke Energy ft: it. . -'b �; -I•'
Facility/Owner Name Facility ID#(if applicable) fL ft• , ti •4,M" (,_f./1--i.
.1700 Dunnaway Road, Semora, NC 27343 ft. ft. ' MAK 0 S 2074
Physical Address,City,and Zip 21:REMARKS
Person ' inclinometer - Intorrnei en 7r7�. rg U t�5
County ' '' Parcel Identification No.(PIN) D;+I tiM -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Certification:
36028145" N 79.3,55''_. w 2-16-2024
Signature of Certified Well Contractor Date
_ 6.Is(are)the well(s):.XPermanent_ of _❑Temporary _ By-signing-this form;-thereby certJ that the-well(s)was(were)constructed in accordance .-.
with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
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7.Is this a repair to an existing well:. Oyes or XNo ' ' copy of this-record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
' . repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details: •
• You may use the back of this page'to provide additional well site details or well
8.Number of wells.constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-seater supply wells ONLY wiih the same construction,you can
submit one_Toni:. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 57' ( ) dayscompletion ft, 24a. For All Wells: Submit this;form within 30 of cam letion of well
For multiple wells list all depths if different(example-3 a(�1 00'and 2Qa 100') construction to the following:
10.Static water level below top of casing: NA (ft.) Division of Water Resources,Information Processing Unit,
!£water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11:Borehole diameter: 7 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to-the address in .
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24a above, also submit a copy of this form within 30 days 'of completion of well
12.Well construction method: Sonic Drilling construction to the following:: ! - ,
(i.e.auger,rotary,cable,direct push,etc:)
.. Division of Water,Resources,Underground Injection Control Program, '
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: -24e.For Water Supply&Injection Wells:
Also'submit one copy of this form:within 30 days of completion'of •
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. j
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division.of Water Resources Revised August 2013
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