GW1-2021-03378_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
P
1.Well Contractor Information:
Michael Hansen 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4381 A
NC Well Contractor Certification Number
15.OUTER CASING for mold-cased wells OR LINER if a livable
Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#:NA FROM I TO DIAMETER ITHICXNESS I MATERIAL
List aft applicable well construction permits(i.e.IRC,County,State,variance,etc.) 0 ft• 52 ft' 2 I tn' s'ch 40 PVC
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SME T'BICKNESS MATERIAL
Agricultural [)Municipal/Public 52 ft- 57 ft' 2 'n� .02'; sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. inI
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 3 ft• Concrete poured
Monitoring Recovery 3 ft. 44 ft* Neat Cement tremie pumped
Injection Well:
_ ty
Aquifer Recharge Groundwater Remediation ft' S0 ft' 3/8 Chips faVl
19.SAND/GRAVEL'PACK'if i6 i6ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 50 ft• 57 ft• #2 sand gravity
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soiltrock in size etc
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft• 16 ft• Fill, brown;sand
4.Date Wdl(s)Completed:4/28/2021 well ID# 16 ft• 48 ft' ASh
5a.Well Location: 48 ft' 52 ft' reen gray sand with silt
Duke Energy DMM6 52 ft- 55 ft- Sapprolite
Facility/Owner Name Facility lD#(ifapplicable) 55 ft' 57 ft' Weathered bedrock
1700 Dunnaway Rd, Semora, NC. 27343
Physical Address,City,and Zip It. ft. r+�
Person 21,REMARKS
County Parcel Identification No.(PII4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J,; 7
(if well field,one lat/long is sufficient) hrG
22 Ce -essillf,�Unit
36.478386 N 79.056888 W \` 1 z �
� Irt,o�►M pb:JR S$''S�3/2021
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
y'this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 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 site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 57 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing:17 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
'
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In add i ition to sending the form to the address in 24a
Sonic above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
i ,
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction!to!the county health department of the county
where constructed-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016