GW1-2021-00531_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS a 14.WATER ZONES
Well Contractor Name ",i`F) ,,y,. FROM TO DESCRIPTION
e.-y •..i ft. ft.
A - 2581 1 5 'tQ't1 ft. ft.
NC Well Contractor Certification Number 1a' 5.OUTER CASING for multi-cased wells OR LINER if a licable
••nrt �!'� ,�y FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION
ft. ft. in.
Company Name '`'Vj;,''a�,'v••'•' - o
16.INNER CASING OR TUBING eothermat closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) 0.0 ft. 70.0 ft. 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 77.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70.0 ft. 85.0 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>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 50.0 rt' PORTLAND BENTONITE SLURRY
ITMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer-Recharge ❑Groundwater_Remediation _.
19.SAND/GRAVEL PACK if a`livable -,__° -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 67.0 ft- 91.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rock type,timin size,etc.
0.0 ft 3.0 ft• RED SILTY SAND
4.Date Well(s)Completed: 02/12/21 WeII ID# GWA-4BRR 3.0 ft 12.0 ft TAN SILTY SAND/BOULDERS
Sa.Well Location:
12.0 ft. 25.0 ft' PWR
CLIFFSIDE STEAM STATION 25.0 ft 85.0 ft• ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
573 DUKE POWER ROAD MOORESBORO 28114 ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21•REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-50.0-67.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
350 21' 61.55" N 810 76' 50.86" w Zn:.,. 1..r---
02/26/21
6.Is(are)the well(s)• OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing This form,/hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 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"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: 85.0 (ft.)
Far multiple wells list all depths iif'diiferent(example-3 r200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
3.0 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 27699-1617
tfwaterlevelisabove casing,use"+"
11.Borehole diameter: 1 0.0/6.0 (in) 24b.For Injection 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 healthdepartment 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018