GW1-2021-00530_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS ,., +") 14.WATER zoNES
Well Contractor Name F; ) i,,., '� 'c. FROM TO DESCRIPTION
A - 2581 5 2021 NC Well Contractor Certification Number 4vti„� a. ft.
$. , TER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION �,.in�rg .i�F O - TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name a...++ t f,=;b u t
1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 fl' 120.0 fl• 2.0 r"• SCH 40 PVC
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120.0 fL 130.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fl. 102.0 ft. PORTIANDBENTONRE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
OAquife[Recharge_ -_ ❑GroundwaterRemediation_
19 SdND/GIZA�I�AC1C if a licable "-""'''` `-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 117.0 ft- 137.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(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,gmin sim,etc.
0.0 ft. 14.0 ft- RED SILTY CLAY
4.Date Well(s)Completed: 02/1 1/21 Well ID# GWA-36BRR 14.0 ft- 33.0 fr. BROWN SILTY SAND
5a.Well Location: 33.0 ft- 61.0 ft' TAN SILTY SAND
CLIFFSIDE STEAM STATION 61.0 ft- 80.0 1" PWR
Facility/Owner Name Facility ID#(if applicable) 80.0 ft, 130.0 ft• ROCK
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 102.0-117.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is sufficient) 22.Certification: �^
350 21' 69.06" N 810 76' 51.83" W 02/26/21
6.Is(are)the well(s)• ©Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [ENo ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
tf 1his is a repair,fill out known hell construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder 421 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 into
construction,only I GW-I 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: 130.0 (ft.)
Igor multiple wells list all depths ifdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 13.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 10.0/6.0 (in) 24b.For Infection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER/AIR
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-I611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018