GW1-2021-03373_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Michael Hansen 14.WATER ZONES F
FROM TO I DESCRIPTION
Well Contractor Name
4381 A
ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells OR LINER if a licable
Cascade Drilling FROM TO DIAMETER TRICIarESS MATERIAL
ft. ft. I in.
Company Name
36.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:NA` FROM To DWMEE;TER TMCXNEss MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) 0 ft• 88 ft 2 'n' sCh 40 PVC
3.Well Use(check well use): k. ft. in
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 88 ft. 93 ft 2 ii .02, sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I ,k
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
1ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 3 ft Concrete, poured
_ Monitoring E]Recovery 3 ft 79 ft' Neat Cement tremie pumped
Injection Well:
_ Aquifer Recharge Groundwater Remediation 79 86 ft 3/8 chips gravity
'19:SAND/GRAVEI:PACK if a""" livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage 86 ft 93 k #2 sand gravity
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _1 Other(explain under#21 Remarks) FROM TO DESCRII color,hardness soiUrock is size,etc.
0 ft• 3.5 ft• Fill, broo wn sand
4.Date Well(s)Completed:4/29/2021 well D# 3.5 k. 80.5 ft' Ashi
5a.Well Location: 80.5 k. 87 ft green gray sand with silt
Duke Energy DMM2 87 ft. 88 ft. Sapprolite
Facility/Owner Name Facility ID#(if applicable) 88 k' 93 k' Weathered bedrock
1700 Dunnaway Rd, Semora, NC. 27343 �-
Physical Address,City,and Zip
Person 21.REMARKS I1
County Parcel Identification No.(PIN) J
LULI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � S6%n U1}t
(if well field,one lat/long is sufficient) 22.Certifies S8i3tioCt
36.479815 N 79.063940 W 5/13/2021
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: Oyes or EJNo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBM T`TAL INSTRUCTIONS
9.Total well depth below land surface: 93 (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@100) 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 Infection Wells: In addition to'sending the form to the address in 24a
Sonic above, also submit one copy of this foam'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
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 fort 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 Revised 2-22-2016
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